Grenfell Tower Fire

Preliminary Report

Head of Grenfell Tower Investigation and Review

Team

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Chapter 1 – Introduction 3

Background to Brigade’s investigation and team 3

Grenfell Tower Investigation and Review Team: Terms of reference 4

Investigation methodology 6

Scope of preliminary report 7

Chapter 2 – Summary timeline of events 9

Chapter 3 – Preliminary observations 12

Theme 1 – Observed failures of the building and its fire safety measures 12

Theme 2 – Operational pre-planning 21

Theme 3 – Command and control 31

Theme 4 – Operations 41

Theme 5 – Brigade Control 62

Theme 6 – Communications 78

Theme 7 – Operational equipment 89

Chapter 4 – Summary of key observations 94

Chapter 5 – Summary of recommendations 98

Chapter 6 – Appendices 100

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Chapter 1 – Introduction

Background to the Brigade’s investigation and review

1 The fire at Grenfell Tower on 14th June 2017 took the lives of 71 people, with a further fatality on

29th January 2018, and left hundreds more with both physical and psychological injuries. Whilst

fire and rescue services are trained to respond to fires in residential high rise buildings, the

incident on the 14th June 2017 was of a scale and rapidity that was exceptional; preceded and

precipitated by a complete failure of the building’s fire safety measures to perform effectively.

Those failures created a set of conditions not previously experienced by the Brigade and provided

a unique challenge for the Brigade and its partner emergency services who responded on the

night.

2 There is much to be commended in the multi-agency emergency response, and many emergency

service personnel demonstrated bravery and selflessness during the night in the pursuance of

preserving life. There can be little doubt that every member of the Brigade and those from the

other agencies who attended, did so with the express aim of saving life and protecting property.

3 The courage of the residents, who, on the night had to endure punishing and terrifying conditions

to escape the building as it became engulfed in fire is recognised and cannot fail to be admired by

all. Similarly, the ongoing fortitude of the families and friends of those residents who were unable

to escape and perished during or shortly after the fire is to be commended.

4 Like all incidents, large and small, there will be learning to be identified and it is acknowledged

that any lessons to be learned and any good practice identified will undoubtedly apply not just to

the London Fire Brigade, but nationally and possibly internationally.

5 The office of the London Fire Commissioner has a statutory duty to review the performance of the

organisation and ensure all learning from incidents is identified, disseminated, and acted upon

where appropriate.

6 This report is a product of the Brigade’s investigation and review but should be considered a

preliminary output only as there is a need for the Brigade and others to conduct further

investigations, in order to achieve a full understanding and reach conclusions.

7 Such was the scale of the incident at Grenfell Tower, a dedicated team within the Brigade, the

Grenfell Tower Investigation and Review Team (GTIRT), was established to understand the

circumstances of the incident and what happened on the night, identify lessons to be learnt, and

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when all the evidence is available, provide an unfettered and comprehensive evaluation of the

Brigade’s response to this unprecedented incident. This investigation has and will continue to

work alongside the statutory processes being undertaken by the Grenfell Tower Inquiry and

Metropolitan Police Service (MPS), whilst acknowledging the primacy of those processes.

8 GTIRT reserves the right to amend any information contained within this report if further

evidence becomes available.

9 The Brigade has sought to support the aim of the Inquiry and MPS in placing the bereaved,

survivors, and residents at the heart of their investigations through the provision of relevant

information, including the products of its own investigations, to ensure the fullest understanding

of the events of the night is achieved for those most directly affected. The internal investigation

team also recognises the traumatic experiences of the Brigade’s staff and their need to

understand the events of the night, and has sought to ensure its own activities and that of other

statutory processes have due regard to the wellbeing of staff.

10 Eighty-three Brigade staff and five staff from other fire and rescue services provided oral evidence

during the Inquiry’s Phase 1 hearings and more than 650 staff have provided voluntary witness

statements to the MPS.

Grenfell Tower Investigation and Review Team: Terms of reference

11 This section sets out the terms of reference and investigation methodology already known to

Brigade’s principal officers to reflect the likely wider interest in the Brigade’s internal investigation

and its outputs.

Aim

12 Develop the fullest possible understanding of the circumstances of the Grenfell Tower fire to

support the identification of lessons to be learnt, and evaluate the adequacy and effectiveness of

the Brigade’s emergency response on the 14th June 2017.

Rationale

13 In order to meet its statutory duties under Health and Safety legislation, the Brigade investigates

all accidents and near misses (collectively known as safety events). The fire at Grenfell Tower on

14th June 2017 was unique in its scale, rapidity and loss of life and as such justified the formation

of a dedicated team to ensure these duties were carried out effectively and efficiently, and

support the Inquiry and MPS investigations.

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14 Objectives

To set-up robust systems to capture all relevant information (documents, witness statements,

emails, images, etc.) and any physical evidence associated with Grenfell Tower and Brigade’s

response to the fire.

To develop and implement a storage and indexing solution for all the information relating to

the Grenfell Tower investigation.

In conjunction with the General Counsel’s Department support the Brigade’s participation in

the Inquiry and establish a ‘disclosure’ management protocol to support the evidence

submissions.

To analyse all relevant and available information to develop a clear understanding of the

Brigade’s involvement with Grenfell Tower prior to the major fire that occurred on 14 June

2017.

To investigate and establish the most likely cause of the fire and the factors that influenced

the rapid fire spread in conjunction with external advisors.

To undertake a comprehensive review of the Brigade’s operational response to the incident

including all the relevant aspects of the operational support and strategic co-ordination

arrangements.

To undertake a comprehensive review of Brigade Control’s response to the incident.

To undertake an assurance review covering all the actions taken by the Brigade in responding

to the Lakanal House fire which occurred on 3 July 2009, including those instigated in

response to the Rule 43 recommendations arising from the Coroner’s Inquest.

To carry out and maintain effective governance and relationships with all relevant external

partners and agencies through the use of Memorandums of Understanding and Working

Protocols.

To work closely with all appropriate Brigade departments to develop an organisational action

plan relating to any lessons learnt arising from the investigation or from recommendations

delivered by the Inquiry

N.B. The report addressing the objective to undertake an assurance review of the actions taken by

the Brigade in response to the Lakanal House fire has been completed and is appended to this report.

Out of scope

15 The investigation or its outputs will not seek to examine or reach conclusions in relation to the

following:

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The cause of death of the people who died and any question of the potential survivability

from the injuries of those who died.

Any matters in relation to civil or criminal liability.

Why the building became so vulnerable to the fire that occurred on 14th June 2017, save to

use the conclusions reached by the Inquiry’s experts where they provide context to actions or

decisions taken by the Brigade on the 14th June 2017.

The activities or response of other agencies, save where they impact on the Brigade’s

response.

Relationship with formal statutory processes

16 The Brigade’s internal investigation is being undertaken whilst the Inquiry and MPS investigations

are ongoing. In addition, the Coroner has opened and adjourned inquests into the deaths

resulting from the fire and it is anticipated that the Inquiry will attempt to address the matters

normally dealt with by the Coroner in the course of the Inquiry’s proceedings.

17 The Brigade has engaged extensively to ensure its actions do not in any way undermine or

prejudice the other statutory processes. In respect of the MPS investigations, ways of working

have been formalised through a Memorandum of Understanding and an Information Sharing

Protocol. The Inquiry has published a number of documents setting out how its terms of

reference will be delivered and as a Core Participant, the Brigade is bound by and adheres to

these protocols.

Investigation methodology

18 The Brigade’s internal ‘safety and learning’ investigation is being carried out in three stages;

19 Stage one is being carried out in two parts, the first being the gathering of information which has

included the copying, recording and referencing of information relating to the incident. The

second part is the use of the Sequential Time Event Plotting (STEP) process to record a timeline of

the actions undertaken at the incident and remotely at Brigade Control.

20 The second stage of the investigation is running concurrently with stage one, and involves the

investigation team building an understanding of what happened at the incident and how it

happened. This understanding of the first seven hours of the incident has developed into the

factual narratives presented in the ‘Operational Response Report Volume 1’ and the ‘Actions by

Brigade Control Report’. Both documents are appended to this report.

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21 The third stage is an analysis to identify those areas that do not align with the expectations of

policy, national guidance and / or training and determine the immediate and underlying reasons

for this, to support improvements and / or avoid a reoccurrence. It is intended to undertake the

majority of stage three of the investigation prior to and during phase 2 of the Inquiry and present

internal findings on the adequacy and effectiveness of the Brigade’s response at the end of the

Inquiry proceedings, once all evidence is available.

22 However, as the internal investigation progresses, where a significant issue or concern is

identified and verified which impacts on public or firefighter safety, and in the opinion of the

investigation team requires action that cannot reasonably wait until the publication of reports,

then these are communicated to the responsible department for consideration. The Brigade

tracks and records any resulting actions taken through its Operational Improvement Process.

23 It is noted that the Brigade has also implemented a Grenfell Tower Fire Improvement Board to

corporately consider operational learning identified by its internal investigation and

recommendations arising from the Inquiry. The Board will direct the implementation of any

improvement actions and assure the effective delivery and embedding of those actions.

Scope of this preliminary report

24 This preliminary report predominantly covers the first seven hours of the incident up to 08:00hrs;

the period of life saving activity and the focus of the Inquiry during its Phase 1 proceedings. The

report also notes historical actions that are considered relevant or provide context to the actions /

decisions taken on the night of the fire. In addition, observations that do not directly relate to the

response on the night of the fire, but may be relevant when the Brigade is considering

improvement measures, have been included to support continuous improvement.

25 The analysis to identify those actions or decisions or outcomes which are not aligned to the

expectations of policy, national guidance and will take some time to complete. It will identify key

lines of enquiry to be investigated to determine the immediate and underlying reasons for such

discrepancies.

26 It follows that much of the work to identify, in particular, underlying reasons will lean heavily on

examining the broader issues of policy and training, and identifying and understanding the

systems and processes used by the Brigade to deliver its statutory functions.

27 In addition, there is a requirement to understand the events that led to Grenfell Tower becoming

so vulnerable to the building wide fire that occurred on the 14th June 2017 in order to provide the

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context for the actions and decisions of those who responded to this incident. These are areas

that the Inquiry will examine during its Phase 2 proceedings and the MPS will also examine as part

of its own ongoing investigation.

28 However, there is learning that can and has been identified, acknowledged, and acted upon from

the evidence available to date, even without fully identifying or understanding the underlying

reason.

29 This report identifies those areas of operational learning within themes and are presented to the

London Fire Commissioner and the Grenfell Tower Fire Improvement Board so that the Brigade

can consider and implement any agreed corrective measures, if it has not already done so.

30 Recommendations that point to matters that the Brigade may wish to consider are provided to

support its decision making have been included in this report.

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Chapter 2 - Summary timeline of events

31 This chapter provides a timeline of key events in the first seven hours of the incident. A minute by

minute factual narrative of the events between 00:54:29hrs and 08:11:00hrs provided in the

Operational Response Report Volume One and the Actions by Brigade Control reports (attached

as Appendices A and B respectively). The entries presented below in italics denote messages.

00:54:29 Initial call to fire in flat 16, Grenfell Tower received

00:59:24 First appliance (G272) books ‘in attendance’ at Grenfell Tower

00:59:28 Second appliance (G271) books ‘in attendance’ at Grenfell Tower and Watch

Manager (WM) Dowden assumes role as Incident Commander (IC 1)

01:00:28 H41S paged as Remote Monitoring Officer

01:07:21 Breathing Apparatus (BA) team One make first entry into flat 16 on fourth floor

01:08:06 Fire begins to break out of the kitchen window of flat 16 on east elevation

01:12:59 Make Pumps 6, 1 Hydraulic Platform (amended to 1 Aerial at 01:13:41)

01:14:21 From G272, residential block of flats of 20 floors, 25 metres x 25 metres, five

roomed flat on fourth floor, 75 per cent alight, high rise procedure implemented

MDT in use, tactical mode Oscar

01:16:05 G272 designated Initial Command Pump (ICP)

01:19:08 Make pumps 8

01:21:15 BA team One confirm fire is extinguished in flat 16

01:21:21 Fire has spread up external cladding to eleventh floor

01:21:24 First 999 call received from a resident inside Grenfell Tower (flat 195, 22nd floor)

01:24:09 Make pumps 10

01:24:33 From G271, can we request attendance of the police for crowd control

01:27:26 Make pumps 15, Aerial Ladder Platforms 2

01:28:12 From G271, this is a persons reported fire

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01:29:11 Make pumps 20, Fire Rescue Units 2

01:30 Fire in external cladding reaches top of the building and begins to spread laterally

01:30:48 First Command Unit (CU8) books ‘in attendance’

01:31:30 Make pumps 25

01:32:08 First Station Manager (SM) (G22S) books ‘in attendance’

01:33 G22S meets with IC 1 and takes over management of Fire Survival Guidance calls

01:36 First aerial appliance (A213) arrives on scene

01:40 H41S arrives at Grenfell Tower and takes over as IC 2 at around 01:50

01:54:30 First Deputy Assistant Commissioner (DAC) (E6) arrives at Grenfell Tower and

takes over as IC 3 from H41S around 01:59

01:57:21 First Group Manager (GM) (E109) books ‘in attendance’ and proceeds to CU8

where he is informed he is the senior officer on scene and assumes command

02:03:13 Make pumps 40

02:06:03 Major incident declared by Brigade

02:11 IC 3 moves to CU8 and appoints E109 as Fire Sector Commander

02:15:49 Make Fire Rescue Units 10

02:34:03 40th pumping appliance now in attendance

02:35 Brigade Control Senior Operations Manager informs Control Room Operators

(CRO) to begin advising callers to leave the building.

02:39:17 From CU8, fire on all floors, from 2nd to 27th floor. Large number of persons

involved. FSG calls being dealt with. Major incident declared. High rise procedure

implemented, TL, ALP, EDBA, Main control, FSG, ground monitor, five jets, safety

cordon in place. Tactical mode Oscar.

02:43:51 First Assistant Commissioner (AC) (BM8) on scene assumes command as IC 4.

02:47 Decision to alter FSG advice from ‘stay put’ to ‘get out’ recorded in decision log.

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02:50:48 London Fire Commissioner (BM 1) books ‘in attendance’ as Monitoring Officer.

03:08 Bridgehead relocated to ground floor lobby due to deteriorating conditions.

04:03 External flame fronts converge at the south west corner of the building, totalling

engulfing the building.

08:11 Last surviving resident (Mr Bonifacio) located in the Grenfell Tower is rescued from

the 11th floor.

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Chapter 3 - Preliminary observations

32 This chapter presents observations themed into seven key areas following a review of the

evidence held by the Brigade and that provided during the Phase 1 proceedings of the Inquiry.

Each key observation is followed by the rationale for its inclusion in this report, together with any

context provided by policy positions or historical actions.

33 The actions the Brigade has completed or are progressing in response to the learning identified to

date are also presented at the conclusion of each key observation or at the end of the section.

34 Recommendations that point to matters that the Brigade may wish to consider are provided to

support its decision making.

Theme 1 – Observed failures of the building and its fire safety measures

35 This section of the report provides a summary of what GTIRT currently understands about

Grenfell Tower, the fire safety provisions within the premises, the apparent failure of those

provisions, and their impact on the residents and the Brigade’s operational response.

36 It draws heavily on the Inquiry’s expert witness reports, particularly that of Dr Barbara Lane, all of

whom have undertaken a significant amount of work to identify how the building impacted on the

events of the 14th June 2017. The expert witness reports provide significant context to the

Brigade’s operational response and the challenges it faced to deliver its key aims to save life,

protect property, and protect the environment.

37 This report provides only a summary of those expert findings. The investigation will consider all

the expert reports in detail during its analysis of the Brigade’s operational response.

38 Grenfell Tower was a 25 storey (including basement and plant room) residential premises built in

the 1970’s. The premises is located on the Lancaster West estate within the Royal Borough of

Kensington and Chelsea. The block originally contained 120 flats over 20 floors with the Ground

and first three levels assigned to non-residential purposes.

39 During the refurbishment undertaken between 2012 and 2016, an additional nine flats were

added within levels one to three, bringing the total number of residential units to 129. This

refurbishment also included the installation of an external rain screen cladding system and works

to the gas supply within the building.

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40 There is also evidence that lift replacement works were undertaken in 2005 and a flat front door

replacement programme was completed between 2011 and 2012.

41 On the 14th June 2017, the fire started in the kitchen of flat 16, on the fourth floor of Grenfell

Tower. The flat is located on the north east corner with the kitchen window projecting onto the

east elevation of the building.

42 The fire was discovered by the resident of the flat, Mr Behailu Kebede, in the corner of the

kitchen adjacent to the east facing window. A fridge freezer was located in this area and the

Brigade’s fire investigation officers believe the fire most likely started in this appliance.

Key observation 1.1 : The external cladding system installed on Grenfell Tower was not

compliant with Regulation B4(1), contributing to the observed failure of the fire safety

measures provided within the premises.

Rain screen cladding system

43 Dr Barbara Lane states in her report, dated 5th November 2018 that ‘The rain screen system,

installed during the refurbishment in 2012 – 2016, was non-compliant with the functional

requirement of the Building Regulations.’

44 Dr Lane further states in her report that ‘the rain screen cladding assembly together with the

insulation fitted to the existing external wall and the missing or defective barriers became part of

successful combustion process. This created a condition (in the event of an internal fire, cavity fire

or external fire) which connected every flat on a storey; and every storey from level three to the

roof, which supported the spread of external fire back into the building , through windows, and

created a series of internal fire events’.

45 She concludes in her report ‘I do not consider it reasonable that in the event of the installation of a

combustible rain screen on a high rise building, the fire brigade should be expected to fully

mitigate any resulting fire event. That is particularly so in circumstances where the fire brigade

had never been informed that a combustible rain screen system had been installed in the first

place.’

46 Dr Lane noted in her report that she had found no evidence that the Brigade had been informed

that a combustible rain screen cladding system had been fitted to Grenfell Tower and therefore

had not had the opportunity to consider the appropriateness of its operational procedures in the

event of a fire at the Tower.

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Fire safety measures

47 Grenfell Tower was provided with a number of active and passive fire safety measures which

were intended to create a layered safety system. They were intended to provide the means for

early internal firefighting. This is achieved by providing the means to limit fire and smoke spread

from a dwelling fire and create the high degree of compartmentation necessary to support the

building owner’s/Responsible Person’s ‘Stay Put’ strategy, which was designated for this

particular high rise residential premises.

48 Dr Lane in her report, dated 5th November 2018, states ‘The high degree of compartmentation

had suffered its primary failure, caused by the fire spreading through the rain screen system’. She

goes on to state ‘The remaining active and passive fire protection measures within the Tower

were required to mitigate the effects of the resulting fire and smoke spread from that rain screen

system fire. These measures were required to mitigate those effects on many floors.’

Evacuation strategy

49 The current statutory guidance does not require a residential high rise premises to be provided

with an interlinked fire alarm system, as the guidance assumes that any fire will be confined to one

flat. The guidance is Approved Document B 2013 states: “The provisions for the means of escape

for flats are based on the assumption that:

a. the fire is generally in a flat;

b. there is no reliance on external rescue;

c. measures in Section 8 (B3) provide a high degree of compartmentation and therefore a

low probability of fire spread beyond the flat of origin, so that simultaneous evacuation of

the building is likely to be necessary; and

d. although fire may occur in the common parts of the building, the materials and

construction used there should prevent the fabric from being involved beyond the

immediate vicinity (although in some cases communal facilities exist which require

additional measures to be taken).”

50 The definition of ‘stay put’ from BS 9991:2015 assumes the same; ‘when a fire occurs in a flat or

maisonette, the occupants of that dwelling evacuate, but occupants of all other dwellings can

safely remain in their dwellings unless affected by heat or smoke or directed to leave by the fire

and rescue service.’

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51 Dr Lane concludes that the guidance in the UK does not require there to be any system or

process to either automatically sound a fire alarm in every flat or to sound an alarm in the common

lobbies outside each flat. Therefore, unless a resident communicates with the emergency services

by calling ‘999’, there is no other automatic or expedient means for operational staff attending an

emergency incident to communicate with residents within the building.

Protected lobbies and stair

52 The means of escape to the final exit at Grenfell Tower was a single staircase provided with a

protected lobby at every storey. A smoke control system, an active fire safety measure, was

provided to protect each lobby and in doing so protect the single escape stair.

53 Professor Torero notes in his report, dated 23rd May 2018; ‘In the Building Regulations and

guidelines applicable to Grenfell Tower there is no requirement for provisions that allow the

occupants of more than the flat of fire origin to evacuate (Section 5.1.7[1]’

54 The evidence from witnesses and the Inquiry’s experts indicate that the lobbies and stairwell

failed to perform on the night of the fire and became compromised by heat and smoke from some

time between 01:21 and 01:40hrs. This created challenging conditions for firefighters and the

residents seeking to self evacuate from the building.

55 There is evidence that heat conditions above 150 degrees centigrade were present in the stairwell

between floors 13 – 16, probably some time around 02:00 – 02:30hrs. This is likely to have

caused a physical and psychological barrier for those above 11th floor to escape around these

times. It is conceivable that these heat conditions were, in part, a consequence of the lack of

firefighting due to the finite limitations of the dry rising main (DRM) capacity. This may have

enabled the fire to spread internally unchecked by firefighting activities that would be undertaken

at a high rise incident that didn’t involve this level of rapid fire spread.

56 Evidence available to date indicates there is a close correlation between the progress of the

vertical fire spread and the presence of smoke in lobbies. Smoke is reported in 13 of 20 lobbies

between 01:19 and 01:38hrs, increasing to 15 out of 20 lobbies by 01:58hrs. By 02:38hrs, smoke

is reported in 19 out of 20 lobbies with severe temperatures on floors six to 10.

57 The failure of the protected lobbies is attributed by Dr Lane to flat front doors failing to control the

spread of fire and smoke from flats into the lobbies and vice versa. This is attributed to a lack of

performance, initially identified by a fire resistance test undertaken by BRE Global, on behalf of

the MPS, on a sample door of the type fitted to the majority of flats within Grenfell Tower.

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58 Flat entrance front doors are considered an important element of the lobby enclosure as they

provide protection to the lobby acting as a means of escape to occupants from a fire in an

adjacent flat. All flat entrance doors are required to be fitted with self closing devices to ensure

the door is closed after a person leaves their flat. Dr Lane was unable to confirm whether these

devices performed as intended, but many witnesses stated in oral evidence that the self closer

fitted to their flat did not work or was missing.

59 In regard to the protected stairs, Dr Lane has noted in her report, dated 5th November 2018, the

following function described in BS9991:2015 ‘Whilst a simultaneous evacuation is normally not

necessary, there will be some occasions where operational conditions are such that the fire and

rescue service decide to evacuate the building. In these situations, the occupants of the building

will need to use the common stair, sometimes whilst firefighting is in progress. As such, the

measures in this British Standard for the protection of common stair are designed to ensure that

they are available for use over an extended period.’

60 Dr Lane further noted in her report in relation to the stair doors; ‘I observed no fire damage in the

stairs consistent with the total failure of a stair door, allowing fire spread onto the stairs’ but does

note ‘the non-compliances I have identified would have contributed to the failure to prevent the

spread of smoke to the stair’.

Mechanical Smoke Control system

61 A replacement mechanical smoke control system was installed in Grenfell Tower during the 2012-

2016 refurbishment, its purpose being to control the amount of smoke entering a lobby and

therefore reducing the risk of smoke spread to the protected stair.

62 The smoke control system was intended to operate on one floor only, as per the requirements of

Approved Document B, and was not expected or designed to operate on multiple floors

simultaneously.

63 A smoke detector was present outside flat 16, the fire compartment of origin, and this detector

should have activated the smoke control system on the fourth floor. There are no reports of

smoke in any other lobby at this time. Evidence from residents report thick black smoke entering

the stairs from the lobby on the fourth floor around 01:20hrs indicating the smoke control system

was not operating as designed.

64 The smoke control system was installed with an override control located in the ground floor

lobby. The control panel enabled the system to shut down or the floor on which the system was

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operating could be controlled. Photographic evidence indicates that the override switch had been

turned from ‘Auto’ to ‘On’, enabling manual control of the system.

65 The smoke control system could also be operated on each floor using a key switch located in each

lobby, enabling the system to operate on that floor. There is no evidence at the time of writing

that any of the lobby key switches were operated successfully during the fire.

Fire lifts

66 Evidence available to date indicates the lifts provided with Grenfell Tower were consistent with

the requirements of a ‘fire lift’ as described in the original design guidance at the time of

construction, rather than a ‘firefighting lift’ as described in Approved Document B.

67 A ‘fire control switch’ was provided at ground level and CCTV footage confirms that Brigade

personnel attempted to secure the lift using this fire control switch but the switch failed to

engage. This resulted in the lifts continuing to operate as normal lifts but not under Brigade

control.

Dry rising main

68 Grenfell Tower was provided with a DRM to support internal firefighting operations. It is noted

that this does not comply with the current guidance which includes for the provision of a Wet

Rising Main in buildings over 50 metres. Prior to 2006, only buildings above 60 metres were

required to have a wet rising main.

69 Dr Lane has stated in her report, dated 5th November 2018, that she believes the DRM was non-

compliant with the original design guidance due to the building height of 67.30 metres. It is

believed the original guidance allowing for a DRM in buildings under 60 metres measured the

height of a building from the DRM inlet to the top of the building. There were no dry rising

outlets on the second and third floors but these were added during the refurbishment when

residential units were added to these levels.

70 However, Dr Lane notes that to comply with the guidance available (Approved Document B) at

the time of the refurbishment, Grenfell Tower would have required the provision of a wet rising

main. In her report, she notes the mechanical and electrical sub contractors stated in

correspondence to RBKC; ‘We are not increasing the high [sic] of the existing riser but we are

adding two additional floors at low level which were previously walkways. We understand the

existing riser is above the current permitted height of 50m, we would therefore need to discuss

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the proposed modification and what measures we need to take to gain approval for the new

system’.

71 RBKC Building Control responded by advising; ‘Essentially the building regulations cannot

require you to improve the existing floors above 50 metres. The regulations only apply to the

work being carried out and additionally you must not adversely affect the existing building’.

72 Dr Lane, therefore, concludes that no works were undertaken as part of the refurbishment to

upgrade the rising main from a dry system to a wet system.

73 Evidence to date indicates that the DRM failed to provide a sufficient number of firefighting jets to

combat the fires present across multiple floors, and the jets established failed to provide sufficient

pressure and flow, presumably because the number of jets connected to the dry rising main

exceeded the capacity of the main.

74 Professor Jose Torero in his expert report, dated 23rd May 2018, states ‘Firefighting protocols for

response to high rise building fires are intimately linked to a single floor fire. Furthermore, for

residential buildings, the firefighters should find, on arrival, a single unit fire’. Professor Torero

goes on to state ‘Fighting provisions, such as water supply, are also dimensioned under the

expectation of a certain magnitude event. If vertical flame spread occurs this will require the

drastic modification of firefighting protocols and advance planning’.

75 Further investigation of the non-compliances identified within Grenfell Tower by the Inquiry’s

experts and the impact they had on the spread of fire and the operational response will be

undertaken by the Inquiry’s expert witnesses in phase 2.

Sprinklers

76 Grenfell Tower was not provided with any fire suppression system such as sprinklers but it is

recognised that there is currently no regulatory requirement for such provision in a building of

this type and age.

Recommendation 1 - The Brigade should continue to work with all stakeholders to identify and

deliver improvements to the regulatory regime to prevent a re-occurrence of the Grenfell Tower fire

and increase the safety of the public and firefighters.

Recommendation 2 - The Brigade should continue to campaign vigorously for the provision of

sprinklers in residential high rise and other types of buildings in order to improve public safety.

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Actions by the Brigade since the fire

77 In the week after the Grenfell Tower fire the Brigade’s Fire Safety Regulation (FSR) department

established a High Rise Task Force (HRTF) to review the risks associated with high rise residential

premises within the Brigade’s area.

78 The Brigade’s FSR department has responsibility for both the delivery of the regulatory fire safety

function and community safety activities.

79 Through an on-going proactive programme of prevention activity targeting and supporting the

most vulnerable members of society, it leads the Brigade’s aim to continue reducing the number

of people who are injured or die in fires.

80 The department’s Fire Safety Inspecting Officers (FSIO) carry out risk based, targeted audits and

inspections of premises under the Regulatory Reform (Fire Safety) Order 2005. Where non-

compliance by the person responsible for the premises is identified appropriate enforcement

action can be taken to ensure any fire safety deficiencies are addressed.

81 FSIOs also respond to consultations from building control bodies under the Building Regulations.

They also provide general fire safety advice as required under the Fire and Rescue Services Act

2004.

82 This team has conducted in excess of 1,500 activities related to residential high rise premises,

including providing reassurance at residents meetings, co-ordinated visits with fire station based

staff and the completion of over 1,100 premises visits.

83 Since the fire, the Brigade’s officers have also consistently engaged with local councils via the

London Councils Fire Safety Group forum. This has enabled the Brigade to share information,

advice and good practice on a range of issues such as Aluminium Composite Material (ACM)

cladding, fire doors and buildings designed on the basis of a ‘Stay Put’ strategy. This engagement

has enabled a consistent fire safety message and helped to maintain links between local councils

and the Brigade’s Fire Safety Teams and Borough Commanders. In addition it has helped the

Brigade to provide community re-assurance, particularly to those people living in residential high

rise buildings. The relationship between the Housing Act, the Housing Health and Safety Rating

System (HHSRS) and the Regulatory Reform (Fire Safety) Order 2005 (RRO) have also been

discussed at this forum, as have topics such as Person Centred Fire Risk Assessments and

Personal Emergency Evacuation Plans.

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84 A number of additional FSR posts have been established as a result of the funding secured from

the Mayor of London, following the Grenfell Tower fire, to enhance the Brigade’s inspection

regime. This has included development officers, quality assurance officers and the re-

engagement of previously retired Inspecting Officers to create a new ‘Specific Projects Group’.

This new group is tasked to focus on high risk property types and complete a more thorough

inspection as a result of the learning from the HRTF inspections.

85 The Brigade’s FSR department has also undertaken the following:

led on assisting the Ministry for Housing, Communities and Local Government (MHCLG) in

producing guidance for buildings that have partial cladding;

provided subject matter expertise to assist Home Office and MHCLG in implementing the

Dame Judith Hackitt recommendations. The Brigade’s officers hold prominent positions on all

the working groups established to deliver the Hackitt recommendations;

designated a Brigade officer to lead the work on reviewing the competency of Brigade’s Fire

Safety Enforcing Officers;

embedded a Brigade officer as a part of the Ministerial task force dealing with remediation of

private tower blocks;

provided, through the FSR Fire Engineering team, assistance to several other fire and rescue

services to help them deal with ACM clad buildings (peer review);

provided, and are continuing to offer, expertise to Home Office, MHCLG, the Expert Panel

and the Dame Judith Hackitt review workstreams. This includes the additional engagement

following the concerns raised over fire doors since it was reported that a door from the

Grenfell Tower block failed the fire spread test;

providing advice and support to London local authorities through regular monthly meetings

of the London Councils Fire Safety sub group. One of the outcomes for which has been a

proposal with the Local Government Association (LGA) and London Councils for a joint

inspection team to deal with uncooperative landlords.

Theme 2 – Operational pre-planning

Identification of risks

86 A range of legislation, including the Health and Safety at Work etc Act 1974 and the regulations

made under that Act, place responsibilities on employers to ensure the health and safety of staff

and others and involves obligations to identify and assess risks arising from work activities and to

take all reasonably practicable measures to manage them.

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87 The Fire and Rescue Service Act 2004 places a duty on the Fire Authority (in London the Fire

Authority is the London Fire Commissioner) to make arrangements for obtaining information to

make provision in respect of firefighting, road traffic accidents and other emergencies.

88 The Fire and Rescue National Framework for England places a duty on fire and rescue authorities

to identify and assess the full range of foreseeable fire and rescue related risks their areas face,

make provision for prevention and protection activities and respond to incidents appropriately.

89 The Framework does not provide any further definition to ‘foreseeable’ but directs authorities to

consider its Local Resilience Forum Community Risk Register and any other local analyses to

ensure all foreseeable fire and rescue related risks are identified and included in their integrated

risk management plan. The Brigade delivers its responsibilities for an integrated risk management

plan through the publication of its London Safety Plan.

90 To determine the foreseeability of an event, it is necessary, as described in the National

Framework, for a fire and rescue service to identify the risks in its local area and assess the

likelihood of those identified risks materialising and the severity of the consequences. Those

events which are deemed to be reasonably foreseeable are those which the fire and rescue

service must adequately plan, train and equip to respond to.

91 Having identified a range of risks, the assessment of likelihood invariably involves considering the

regulatory controls undertaken or administered by others which impact on the scale and

likelihood of any event occurring. Building regulations are an effective example of this in regard to

buildings, whether in the context of fire or any other matter which may impact on their safety.

Similarly, Department of Transport regulatory rules are provided to control the safety of the

country’s transport network and these serve to reduce the risk of an incident or limit the scale of

an incident.

92 One of the key factors which fire and rescue services must consider when assessing and

identifying risk in the built environment is the extent to which statutory controls are already in

place to regulate the risk. Fire and rescue services necessarily rely on the existence of such

controls when making provision for the carrying out of their functions1.

1 Part 2 of the Fire and Rescue Services Act 2004 ss 6-20

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Key observation 2.1 : Any knowledge concerning the risks associated with cladding

systems may not been recognised and communicated effectively across the Brigade.

93 Evidence adduced in Phase 1 of the Grenfell Tower Inquiry, such as that contained in the ‘Tall

Buildings’ presentation2 suggests that the knowledge cladding systems may have presented a risk

was fixed, if not completely understood, within some sections of the Brigade.

94 The risks identified in the presentations were not solely focussed on the combustibility of

cladding systems but also addressed the impact that such systems might have on fire behaviour,

including elongation of flames behind rain screen systems and / or unseen fire spread in any

cavities behind or within the cladding system. Similar information is contained within the BRE

Global publication ‘BR 135’, issued in March 2013, which also discusses the fire performance of

external thermal insulation for walls in multi-storey buildings.

95 The knowledge contained within the ‘Tall Buildings’ presentation was developed and used within

the Brigade to educate Fire Safety Inspecting Officers, Fire Engineering staff and operational

Senior Fire Safety Officers (SFSOs).

96 Fire Safety Inspecting officers are responsible for the Brigade’s fire safety enforcement duties,

primarily in respect of the Regulatory Reform (Fire Safety) Order 2005 (RRO), seeking guidance

when necessary. They carry out fire safety inspections/re-inspections and audits of all premises

types to assess the risks and the adequacy of their fire precautionary arrangements.

97 LFB Fire Engineers undertake casework on projects where fire engineering has been utilised as

either part of the design for new/refurbished buildings or existing solutions for a building. Their

primary role is to review fire engineering design submissions received as part of the Building

Regulations consultation process. Through this role they provide technical support to area fire

safety teams, Fire Engineering Liaison Officers (FELOs) and act as subject matter experts at

internal and external meetings. They may provide representation of technical opinion through

committee representation for fire safety engineering technical documents such as new and

revised British Standards, Approved Documents, Industry guidance and Codes of Practice.

98 SFSOs provide an emergency response role. They are mobilised in line with Policy Note (PN) 412

Mobilising policy. Their role includes a range of advice and support to Incident Commanders

2 LFB00003521

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during the response phase of an incident. They can advise on what passive and active fire safety

facilities might be in a building and how these may assist with operations.

99 It is clear from evidence provided to the Inquiry by Brigade witnesses and the Brigade’s internal

investigation that information such as that contained within the ‘Tall Buildings’ presentation and

BR 135 was not communicated effectively to those concerned with the development of

operational policy and training.

100 Cladding is mentioned in both the 2014 and the earlier 2008 version of Generic Risk

Assessment (GRA) 3.2 ‘Firefighting in high rise buildings’ which informed the Brigade’s local high

rise firefighting policy, PN 633, and in both documents, cladding is mentioned in the ‘Planning’

section, as an example of a building construction feature that should be included as part of the

information a fire and rescue should gather about high rise buildings.

101 The Brigade had a significant role in reviewing GRA 3.2 as it had identified and was in the

process of implementing a number of lessons learnt from the high rise fire which had occurred at

Lakanal House in July 2009. This incident had led to a significant loss of life and a range of

learning had been identified through the Coroner’s Inquest and the internal investigations which

had preceded it. The Brigade’s learning from this fire was incorporated into the Lakanal House

Case Study, which was implemented as mandatory training for all operational staff in 2014.

102 The Brigade’s recent report3 into national guidance and local policy for high rise firefighting,

commissioned by the Operational Policy and Assurance (OPA) department following the Grenfell

Tower fire states the use of the phrase ‘such as’ in 2014 version was intentional and indicative of

the fact that the building features listed were not meant to be either definitive or prescriptive, but

were offered as a guide to the kind of information fire and rescue services should consider

gathering about high rise buildings.

103 The report noted that cladding is not identified as a specific hazard in the ‘Hazard and risk’

section of either version of GRA 3.2 and reflects on the fact that no reference was made to

cladding in the responses that were made by any of the consultees who offered feedback

regarding the development of the 2014 version of GRA 3.2. The report details that cladding was

included within ‘Planning’ because, as an outer layer on one or more faces of a high rise building,

it was understood that the use of this material would create a void which had the potential to

promote an abnormal degree of external spread of fire or smoke, as referenced in BRE 135 and

3 GTIRT19-000737

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the ‘Tall Buildings’ presentation. As such, cladding was noted alongside timber-framing, surface-

mounted trunking and voids as an example of a building construction feature that should be

recorded within the information to be gathered by fire and rescue services in relation to high rise

premises.

104 The Brigade’s PN 633, reviewed in 2015 following the publication of the 2014 version of the

GRA, does not include cladding as one of the eight examples of building construction features

that may be found in a high rise building but it is noted that neither GRA 3.2 or PN 633 purported

to list all of the building construction features that may be found in a high rise building and may be

relevant to high rise firefighting.

105 More recently, the Brigade responded to a fire at Shepherd’s Court in Shepherds Bush in

August 2016 which originated in a two bedroom flat located on the seventh floor of the 20 storey

purpose built block. The fire was of particular interest to the Inquiry due to the external fire

spread which spread vertically from the seventh floor, after breaching a window, to the 12th floor

and penetrated back into the building. It is noted, however, that the characteristics of the building

were significantly different to Grenfell Tower. It did not have a rain screen cladding system fitted

and the compartmentation within the building was maintained to a satisfactory standard, enabling

the Brigade to deploy resources to contain and extinguish the fire on each floor.

106 The Brigade’s fire investigation into Shepherd’s Court determined that the external fire spread

involved external panels fitted directly under and above the windows. Further investigation

identified the panels were constructed with a plywood backing and an 1mm metal face,

sandwiching a polystyrene foam. The investigation concluded that the fire attack on the panels,

arising from flames breaching the window initially, was likely to have assisted the fire in spreading

up the outside of the building.

107 It is noted that the result of this investigation was communicated to Hammersmith & Fulham

Council and raised by letter with other borough councils and registered landlords to inform them

of the potential risk and request that they include consideration of that risk in their fire risk

assessment for premises within their respective property portfolios.

108 At this time, there is no evidence that the issue with the infill panels identified by the

Shepherd’s Court fire was communicated to those departments responsible for operational policy

or training.

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Other UK fires involving cladding

109 There have been other fires in the United Kingdom such as the fire at Garnock Court in

Scotland in 1999, which led to the introduction of the Building (Scotland) Regulations 2004 which

came into force on 1 May 2005. It contains the mandatory regulation: ‘Every building must be

designed and constructed in such a way that in the event of an outbreak of fire within the

building, or from an external source, the spread of fire on the external walls of the building is

inhibited.’

110 At Westminster, the Select Committee on Environment, Transport and Regional Affairs

examined the issue of fire spread in buildings via external cladding systems following the Garnock

Court fire and concluded in December 1999; ‘The evidence we have received during this inquiry

does not suggest that the majority of the external cladding systems currently in use in the UK

poses a serious threat to life or property in the event of fire. There have been few recorded

incidents involving external cladding, and, although in our view any loss of life in incidents such as

these should be prevented if at all possible, neither have there been many deaths (indeed, it is

uncertain whether any of the deaths in the fires of which we have been informed can be directly

attributed to excessive fire spread via the external cladding). Furthermore, the responsible

attitude taken by the major cladding manufacturers towards minimising the risks of excessive fire

spread has been impressed upon us throughout this inquiry.’ 4

111 Historically, fire and rescue services have been provided with national guidance, in addition to

the Generic Risk Assessments, through the following publications:

Fire Service Circulars, issued by HM Government and replaced by Fire and Rescue Bulletins

from August 2010

Dear Chief Officer Letters, issued by HM Inspectorate of Fire Services up to June 2004

Fire Service Manuals, issued by HM Government

Manuals of Firemanship, issued by Home Office and replaced by the aforementioned Fire

Service Manuals

112 The information provided by these publications was broad in scope, ranging from operational

guidance, training requirements to notification of events or lessons learned that may impact on

fire service operations or the safety of personnel, both nationally and internationally. It is noted

4 https://publications.parliament.uk/pa/cm199900/cmselect/cmenvtra/109/10907.htm

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that the different regulatory environments that exist in other countries often impact on the

usefulness of any analysis of international fire events.

113 Since 2018, the function of capturing operational learning from UK fire and rescue services and

the wider international fire and rescue sector has been undertaken by the National Operational

Learning (NOL) secretariat. Learning events are collated and analysed by the NOL secretariat, in

partnership with experts across the fire sector and academia to check it against the guidance

framework of hazards, control measures, strategic and tactical actions. The secretariat propose

any recommended changes to guidance to the National Operational Learning User Group

(NOLUG) who decide on the required actions.

114 NOLUG is a national group formed of strategic leads from across UK fire services, multi agency

partners and representative bodies. It is the decision making body of national learning and sits

within the National Operational Effectiveness Working Group.

Operational Risk Information

115 The Brigade’s PN 800 ‘Management of operational risk information’ provides the policy

framework and guidance for personnel on the Brigade’s risk based approach to identifying,

gathering and disseminating operationally important site risk information and recording it on the

Operational Risk Database (ORD).

116 In April 2012, the Department for Communities and Local Government (DCLG) and the Chief

Fire and Rescue Advisor’s Unit (CFRAU) published the Fire and Rescue Service Operational

Guidance - Operational Risk Information. The purpose of the guidance is explained as “…robust

yet flexible guidance on developing and maintaining a consistent approach to managing,

processing and using strategic and tactical operational risk information that can be adapted to the

nature, scale and requirements of the individual Fire and Rescue Service.” and “… to provide

consistency of approach that forms the basis for common operational practices, supporting

interoperability between Fire and Rescue Services and other emergency responders … to

support safe systems of work … and enhance national resilience.”

117 Following publication of this national guidance, the Brigade’s Strategy and Risk department

undertook a gap analysis to determine the extent to which the Brigade was compliant with the

published guidance. The outcomes were presented to the Corporate Management Board on 6th

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March 20135 and noted that the Brigade’s system was robust and largely compliant with national

guidance.

118 The Brigade’s ORD replaced the previous Central Risk Register (CRR) in April 2011 and is the

main database which holds location-based operational risk information. The primary purpose of

the ORD is to record significant hazards and risks, including any less obvious hazards and any

unique control measures in place, as well as any particular tactical plans or command and control

procedures required. Appropriate information and a tactical plan, when required, is added to the

ORD by station personnel via the Station Diary application and assured by Station Commanders.

119 The information held in the ORD is made available to crews via icons on maps displayed on

appliance Mobile Data Terminals (MDTs) and can also be accessed by the subsequent ICs

through the systems available on the CUs.

Key observation 2.2 : The Operational Risk Database entry for Grenfell Tower was not

populated in accordance with PN 800.

120 Evidence provided during Phase 1 of the Inquiry indicated that the ORD entry for Grenfell

Tower did not provide all of the information that may have been relevant to the premises, and

provided some information that was inaccurate. This included the absence of an electronic

Premises Information Plate (ePIP) which may have provided information to assist crews including

dimensions and the basic layout of the premises, number of floors, details of available hydrants

and the rising main, together with the locations of lifts.

Key observation 2.3 : There is a lack of consistency in the standard of premises risk

information held on the Operational Risk Database.

121 Further investigations by GTIRT and the Operations Directorate have ascertained the lack of

quality identified in the Grenfell Tower risk information is an issue replicated more widely in the

location-based operational risk information held by the Brigade. This can include but is not limited

to inaccurate information, incomplete tactical plans, and the absence of an ePIP for the premises.

5 13-CMB043 Operational risk information – LFB response to national operational guidance

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Key observation 2.4: The Brigade has not undertaken Premises Risk Assessments for all

residential high rise premises to determine the level of risk associated with these

premises.

122 The Lakanal House Incident Assurance Review report (Appendix D) identified the Brigade’s

intention, following the Lakanal House incident, to undertake a premises risk assessment (PRA)

on all residential high rise premises to determine the level of risk associated with those premises.

123 A PRA is normally carried out by the operational staff in whose area the premises is located. In

almost every case a site visit is required and the template provided in PN 800 ‘Management of

operational risk information’ assists in this process by identifying potential hazards and applying a

score to that hazard. The template also identifies controls that reduce the risk such as the

presence of a dry or wet rising main.

124 Using the identified areas of hazard on the PRA template, the visiting operational staff apply a

risk assessment to the hazards and in conjunction with the local SM decide the level of risk within

the premises and the resulting action to be taken.

125 The level of risk is applied to a risk grading matrix, which determines how often the premises

should be visited, whether it requires an on site exercise, and whether hazard information or a full

tactical plan needs to be recorded. It is noted that premises will not all meet the risk threshold to

justify inclusion on the ORD, due to the absence of any premises based risks that may impact on a

safe and effective operational response.

126 There are approximately 6900 residential high rise premises in London and it is noted that some

boroughs have a disproportionately high number of high rise residential buildings and other

premises that may require inclusion on the ORD. It is recognised that this presents a challenge for

the Brigade to balance fulfilling the gathering of operational risk information in these areas with

ongoing activities undertaken by crews in relation to community safety and training, in addition to

providing a response to operational incidents.

127 Premises which meet the risk threshold to require inclusion on the ORD are then subject to a

requirement for periodic 7(2)d visits, at a frequency determined by the risk rating applied to the

premises as indicated by the PRA. The primary aim of 7(2)d visits is to assist crews to remain

familiar with any specific risks associated with the premises and any unusual control measures not

generally covered in policy and update or confirm any existing risk information. They are not the

primary mechanism to initially identify the level of risk associated with a premises.

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Key observation 2.5 : There is an inconsistent level of knowledge and understanding

amongst operational staff in relation to undertaking 7(2)d visits.

128 A number of Brigade witnesses provided oral evidence to the Inquiry that demonstrated a good

knowledge of the ORD and the purpose of 7(2)d visits, however this was not replicated by all

witnesses suggesting there is an inconsistent level of knowledge and understanding amongst

staff, despite the current training and guidance available.

129 Section 7(2)d of the Fire and Rescue Services Act 2004 places a responsibility on the Fire and

Rescue Authority to make arrangements for obtaining information needed for the purpose of

extinguishing fires in its area, protecting life and property in the event of fires in its area, rescuing

and protecting people in the event of a road traffic accident, and rescuing and protecting people

in the event of emergencies.

130 A Watch based training package on conducting 7(2)d visits was included as mandatory training

in Operational News 24, issued in March 2013 and has been refreshed through station based

training periodically. Operational risk information and 7(2)d visits are also addressed in the

Lakanal House Case Study, issued as mandatory training for all operational staff in 2014.

131 In addition, there are a number of documents available on the Brigade’s intranet providing

guidance to staff on outside duties, including 7(2)d visits, and the ORD, together with advice for

SMs on quality assuring ORD entries.

132 However, it has been observed that the information provided in the Brigade’s policies and

associated training packages in relation to undertaking 7(2)d visits is not completely aligned. PN

800 directs operational staff to pay particular attention to nine areas, whilst PN 633 Appendix 1

provides a list of 22 items for crews to consider and ensure they are familiar with.

133 The Fire and Rescue Service Operational Guidance – Operational risk information, provides no

practical guidance on undertaking 7(2)d visits and focusses on the process for identifying

premises which may become subject to 7(2)d visits.

Recommendation 3 – The Brigade should consider reviewing its policies and training packages

relevant to 7(2)d visits to ensure consistent guidance is provided to operational personnel.

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Key observation 2.6 : There is no established means for crews providing an emergency

response to premises outside of their own station areas to be aware of any fire safety

deficiencies that may have been identified.

134 The Brigade has an established process to ensure that local crews are notified when a premises

in their own station area has been issued with a Notice of Deficiencies or an Enforcement Notice

following a fire safety audit or notification of an Alleged Fire Risk6. This is to ensure crews are

aware of any issues that may impact on firefighting operations and / or increase the risk to

firefighters or members of the public.

135 During further investigation into the area of operational risk information, it is noted that the

Brigade, necessarily, has a pan London approach to fire cover which on occasion may lead to non-

local crews being the first attendance to a fire or other incident type. Currently there is no system

to ensure information about any identified deficiencies in the fire safety provisions in a premises

are available to all operational crews that may be required to provide an operational response.

Recommendation 4 – The Brigade should consider how to ensure information relating to identified

fire safety deficiencies in a premises is available to all operational crews.

Actions by the Brigade since the fire

136 The Brigade has instigated a corporate project to review and, where necessary, improve its

system for the gathering, recording and dissemination of operational risk information. The

objectives for the project are identified as:

Review and rationalise current risk information systems to evaluate the current entries and

carry out the necessary interventions to increase the underpinning knowledge and

understanding of staff with these systems.

To create a policy that encompasses understanding and identifying risk and provides a

uniform approach to gathering, recording, prioritising and sharing of operational risk

information.

The relevant risk information will be easily available to the right people at the right time in a

form that is easy to understand and use.

Staff will have a better understanding of their role whilst assessing risks with regards to

reducing the risks to firefighters and the risks to the public.

6 An Alleged Fire Risk (AFR) is a notification from an individual to the Brigade reporting their concerns about the fire safety arrangements at a particular premises.

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To ensure staff have a better knowledge and understanding of risk and their responsibilities

of ensuring the data collected and entered is relevant and accurate.

137 The project will link to and complement planned Information Technology (IT) system rebuilds,

which aim to provide the data management framework and portal for an integrated approach to

risk recording and notification across all the areas of service delivery.

Theme 3 – Command and Control

Incident Command

138 The Brigade sets out its incident command framework through a series of policies owned by

the OPA department. Those policies are broadly but not fully aligned to National Operational

Guidance (NOG). The key difference is the Brigade currently continues to operate the Decision

Making Model (DMM) it has used successfully for many years and has not adopted the Decision

Control Process (DCP) included within NOG – Incident Command, published in 2016.

139 The DMM was included in the ‘Incident Command, Fire and Rescue Service Manual’7 to

support commanders during their operational decision making. The model is a simple flow

diagram which guides users through the decision making process in an organised way. The

process aims to reduce the potential for information to be missed and requires objectives to be

set and implemented. The DMM provides the framework to support Incident Commanders (IC)

to manage operational incidents effectively and bring them to a safe satisfactory conclusion. A

diagram is provided below for illustrative purposes.

7 HM Government publication superseded by National Operational Guidance – Incident Command in January 2016

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140 The DMM is formed around two main activities, Deciding and Acting. Each stage identified in

the model falls into one of these activities.

Deciding - gathering and thinking about all available information; identifying appropriate

objectives; defining a plan; and considering the results of evaluations.

Acting - communicating the objectives and tactical plan; controlling the activity; and

evaluating the outcome of the plan.

141 The model also serves as a golden thread through the Brigade’s operational review and

debriefing framework, including the Performance Review of Command (PRC) process.

Recommendation 5 - It is recommended that the Brigade determines whether to retain the DMM

or move to the DCP. It is acknowledged the Brigade needs to consider the challenges and benefits of

implementing such a wider ranging and fundamental change to its incident command framework, at a

time of significant organisational change and other improvement programmes.

Human factors impacting on command and control

142 The following paragraphs provide a summary of information set out within NOG in relation to

the impact of human factors on incident command and their relationship to the events observed

during the Grenfell Tower fire. It notes that the influence of human factors on behaviour and

performance at incidents should not be underestimated or overlooked when evaluating

performance or effectiveness.

143 Human behaviour will influence individual activities in the operational environment of an

incident in complex and significant ways. Whilst characteristics such as personality are fixed,

others such as competence, skills, attitudes and beliefs can be enhanced, influenced and

changed.

144 The guidance states that although personality, situation, and environment play an important

role in behaviour, an individual level of risk acceptance dictates what this behaviour will be.

Individuals subconsciously accept the level of risk they are comfortable with. In the operational

environment of an incident, individual influences on behaviour will include issues such as

personality, their attitude to safety and their risk perception.

145 NOG observes that stress will also adversely affect an individual’s behaviour. Acute stress is a

reaction to sudden, unexpected events such as those that may be experienced when working in a

dynamic, high-risk environment when commanding an incident. Such stress will involve

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significant physiological and psychological effects akin to the fight, flight or freeze responses

observed in animals.

146 There can be little doubt the personnel who attended the Grenfell Tower fire would have

experienced acute stress to a greater or lesser degree, particularly those making risk critical

decisions and those who entered the building to undertake firefighting, search and rescue

operations. Many of those who attended the incident required counselling support afterwards

and for some that support is ongoing, demonstrating the stress and trauma experienced on the

night.

147 The guidance states that acute stress can adversely impact on incident command in a number

of ways. It can impair situational awareness and decision making leading to a decline in individual

and team performance.

148 Stress and anxiety take up part of a person's mental processing capacity and can distract

attention from the situation and reduce available capacity to focus on and understand

information. Failing to recognise important information or not processing it properly may lead to

an inaccurate mental picture of the situation.

Recommendation 6 - The Brigade should consider the extent to which human factors affecting

command and control are addressed in policy and training.

Key Observation 3.1 : The scale and rapidity of the incident, combined with human

factors, impacted on the ability to maintain situational awareness.

149 From approximately 01:20hrs on the night of the fire, as the incident began to develop rapidly,

situational awareness amongst those in command roles became reduced in relation to what was

happening within the building in regard to internal fires and the resulting conditions. From around

this time, the situation escalated with a rapidity and scale not previously experienced by the

Brigade, placing those in key roles under stress.

150 Brigade witnesses who performed command roles describe in their evidence the difficulties of

gaining a clear understanding of the developing situation within the building. Around this time, it

is evident that radio communications started to become problematic as discussed later in this

chapter (Theme 6 refers). In addition, fire survival guidance (FSG) calls started to be received

from 01:21hrs by Brigade Control and a large volume of information had to be transferred to and

processed on the incident ground.

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151 The rapidly developing situation and the resulting human factors identified in the preceding

paragraphs may have contributed to challenges in maintaining effective situational awareness. It is

necessary to gather further information and review that evidence to develop a fuller

understanding and reach a conclusion.

152 It is clear that reduced situational awareness can have a number of potential impacts on the

command and control of an incident. The ability to identify and prioritise objectives and develop a

tactical plan can be compromised by reduced situational awareness.

153 Effective incident command, particularly at large and complex incidents, requires the

delegation of responsibility and authority through the process of sectorisation to limit the spans of

control of one individual. NOG notes that excessive spans of control have the potential to

adversely impact on the ability of an individual to manage an area of responsibility effectively.

154 Officers tasked with managing an operational or functional sector must be briefed so they fully

understand their objectives, how these objectives fit into the tactical plan, and the parameters of

their responsibility and authority. The evidence from many witnesses suggests that briefings

included minimal information about the developing situation, hazards, risks, objectives, and

priorities. It is likely those providing the briefings did not have the time or sufficient situational

awareness to conduct a detailed briefing and therefore officers nominated for command and

functional roles were often reliant on building their understanding on arrival at their respective

scene of operations.

155 During the Grenfell Tower fire, the breadth and volume of information, even in the early stages,

that needed to be understood by commanders to gain and maintain situational awareness was

considerable. It included rapid external fire spread, fire penetration back into the building, the

effectiveness of the internal compartmentation and its effect on internal fire spread, the ongoing

self evacuation by residents and the FSG call information relating to those still located within the

premises.

156 The scale of this challenge should not be underestimated, particularly in the context of an

incident that was unprecedented in the experience of those attending the incident and it is also

necessary to acknowledge the human factors described earlier.

157 NOG observes that human perceptual and memory systems are not infallible. A strong focus on

one part of the situation, or element of the environment, can lead to other sources of information

being neglected or missed resulting in reduced situational awareness. Impaired communication

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resulting from stress is likely to affect teamwork, leading to a lack of shared understanding about

the situation, objectives and plan.

Task focus

158 Analysis of the evidence suggests that many officers became, understandably, task focussed at

stages during the incident. Becoming task focussed can lead to becoming unduly fixed on some

elements of an incident, rather than looking at the incident or their area of operations as a whole.

159 In evidence many officers stated that they had often made assumptions that processes were

working effectively and information was being communicated to those that needed to be

updated. A number of witnesses described not having the time to assure themselves that things

were being done effectively and stated they trusted subordinates were undertaking their roles

and any actions effectively.

Extended period undertaking tasks

160 A number of supervisory officers also provided evidence that they were overwhelmed by the

scale of the tasks for which they were responsible. In some cases, these supervisory officers were

not provided with further support or assistance and were often performing those roles for many

hours.

161 In addition to welfare concerns related to undertaking an extended period in a dynamic and

stressful role, NOG notes that ICs should be aware of the effects of fatigue on themselves and

others, and ensure people are relieved appropriately. It also states that actions should be taken

before fatigue begins to reduce performance.

Actions by the Brigade since the fire

Briefings

162 The Brigade has included an article on briefings at incidents in its latest Operational News

publication (Ops News, Issue 36), published in February 2019. The article highlights the DMM

(PN 341 refers) as the preferred tool to inform effective briefings.

163 Operational News is a six monthly publication provided to all operational LFB staff. It is one of

Brigade’s key mechanisms to raise awareness of good practice and areas for development, and

are supported by links to training materials. The training that is attached to each subject area is

categorised as either; mandatory for all operational staff, mandatory for specific staff groups, or to

be delivered at the discretion of the WM dependant on current development needs. The training

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is completed by staff in accordance with the categorisation of the training intervention and

recorded in the Station Diary8.

New technology to support situational awareness

164 The Brigade has recognised that drones may provide officers on the incident ground a range of

new capabilities that have the potential to improve situational awareness and decision-making at

incidents. It commenced an operational trial in October 2018 to evaluate two different drones for

a six month period. Each drone is operated by a minimum of two operational staff, one who pilots

the drone and one who operates its on-board cameras. The two members of staff will operate

from a Brigade vehicle in a safe area and will cordon off a small area to operate the equipment.

165 The drone team will attend a range of different incident types during the trial to establish

exactly how drones can best serve the Brigade in future. The trial will assist to answer a number of

questions, such as many drones are required to provide pan-London cover, call out times, which

incidents to deploy them to, and many other practical considerations.

166 In addition to improving firefighter safety, the obvious benefit is that drones will provide an

aerial view of an incident without reliance on imagery from an partner agency such as NPAS

whose assets may be employed at another location.

167 The Brigade anticipates drones to be more useful at some incidents than others, such as large

warehouse fires when observation by firefighters at ground level or from aerials is difficult or

hazardous, or grass fires over a large area that may develop spontaneously in new locations.

168 The trial will evaluate the usefulness and effectiveness of the drones at residential high rise fires

during the six month period but it is anticipated they will provide a useful tactical option in both

the response and recovery phases. The Brigade has received permission from the Civil Aviation

Authority to fly a drone throughout most of London at low altitudes and close to buildings.

169 The drone can remain in flight for up to one hour and has two cameras, a heat-sensitive camera

that can 'see' through thick smoke and detect hot spots, such as the seat of a fire and members of

the public who may be trapped by a developing fire. The second camera has 30x magnification

and can read a number plate from some distance away, up to half a kilometre. The drones can

8 Station Diary is a software application provided to enable the effective management and recording of the activities of

station based staff.

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also fly up to seven kilometres from the pilot, although it is noted that tall buildings may limit the

distance in practice.

170 The footage shot by each camera is stored on a memory card that can be removed and the

footage stored after each incident to assist with any post incident review.

Key observation 3.2 : The rapid escalation of the incident impacted to a limited extent on

command handovers.

171 It is noted that the initial IC, a WM, was in charge of the incident from 01:00hrs until approx.

01:50hrs when the role was taken over by one of the two SMs mobilised at 01:15hrs on receipt of

the ‘make pumps six’ message. Further SMs were mobilised to perform the roles of Press Liaison

Officer (PLO) and SFSO, together with a GM. These mobilisations were all in accordance with the

requirements of the Brigade’s mobilising policy, PN 412.

172 Additional officers, including a DAC, were mobilised in accordance with PN 412 at 01:20hrs

and 01:26hrs following the ‘make pumps eight’ and ‘make pumps 10’ assistance messages. This

was followed by further officers, including an AC, following ‘make pumps 15’.

173 The attendance times following mobilisation for all officers assigned to Grenfell Tower was

broadly compliant with Brigade expectations i.e. SM on scene in 20 minutes after mobilisation,

GM on scene in 30 minutes and DACs and above on scene in 60 minutes after mobilisation. The

exception was the GM first mobilised, who was off duty, and had been mobilised in error and

therefore understandably did not respond to his pager. The failure to respond by contacting

Brigade Control was not noted by Control staff who were, at that time, inundated by emergency

calls and did not follow up the ‘failure to respond’ or mobilise a replacement GM.

174 In the context of the rapid escalation of the incident from the predetermined (PDA) to ‘make

pumps 25’ in less than 30 minutes, it is not surprising that a WM remained as the IC during this

period and beyond.

175 There was an opportunity at around 01:40hrs for the first SM on scene to take over the incident

but this was jointly rejected in favour of the SM taking over the coordination of the FSG calls

being received, knowing that a second SM was en route and would arrive shortly. This decision

suggests both officers considered that the FSG calls represented the greatest opportunity to save

life.

176 The rapidity and scale of the incident also created a situation that led to two officers

simultaneously performing the IC role for a short period, one located by the Tower and the

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second officer located in CU 8. This situation developed due to their different arrival points at the

incident, with the first having to pass the current IC located on the south east corner of the Tower

and leading him to immediately taking command of the incident. The second officer approached

from a different direction and passed CU 8 and was informed he was the most senior officer in

attendance and therefore took command. There is no evidence at this stage that this inadvertent

situation had any adverse consequences on the command and control of the incident.

177 It is noted that the process of command handovers is often challenging during incidents that

escalate very quickly, as identified by Her Honour Frances Kirkham during the Lakanal House

Inquest. Following the Inquest, a Rule 43 recommendation was directed at the Brigade noting ‘It

is recommended that the Brigade review its policy and procedures concerning incident

command, having regard to whether it is effective for the choice of IC to be tied closely to the

number or type of appliances attending an incident and the effectiveness of a policy which may

result in rapid and frequent changes of IC’.

178 In response, the Brigade implemented changes to its incident command thresholds to reduce

the number of handovers required, as part of series of measures to improve the delivery of

effective incident command.

Key observation 3.3 : Effective early information gathering enabled the ‘on arrival’ tactics

and actions identified in PN 633 to be implemented effectively by the crews who formed

the pre-determined attendance for the incident.

179 Information was gathered effectively by the initial IC in the early stages of the incident and used

to select and implement a safe system of work to deliver the ‘on arrival’ tactics and actions

detailed in the Brigade’s high rise firefighting policy. Experts have surmised that these actions

resulted in the extinguishment of the fire in the kitchen of flat 16 within 21 minutes of arrival on

scene, but not before the fire had breached the window and ignited materials contained within

the combustible rain screen cladding system fitted to the exterior of the building.

180 It is recognised that crews had to overcome a number of issues in delivering the ‘on arrival’

actions including accessing the building and the failure of the lift to respond to the fire control

switch.

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Key observation 3.4 : There was effective early recognition of resourcing requirements by

incident commanders.

181 There was a necessary and effective focus on identifying resource requirements as the fire

breached the kitchen window of flat 16 and ignited materials in the cladding system, particularly

by the initial IC who sent a number of ‘assistance’ messages up to ‘make pumps 25’. This

escalation of resources was reinforced by subsequent ICs who ordered further pumping and

specialist appliances resulting in the attendance of:

40 pumping appliances

14 Fire Rescue Units

4 aerial appliances

7 Command Units

6 Operational Support Units

24 senior operational officers.

Key observation 3.5 : Recording of decisions, rationale, objectives and tactical plans were

in some regards ineffective.

182 A number of witnesses discussed their objectives and tactical planning during their evidence to

the Inquiry. One Brigade witness described in oral evidence their thinking around the evacuation

of the building. The witness described his thoughts as prioritising those making FSG calls and

those residents located in the immediate vicinity of the fire, followed by a systematic search

beginning on the upper floors of the building.

183 However, there is little evidence that decisions and the rationale for them, objectives and

tactical plans were effectively recorded during the incident. The recording of ‘key decisions’ such

as the application of operational discretion is discussed in more detail below (Key observation 3.7

refers).

184 The recording of objectives and tactical plans are crucial to support effective communication

with others within the command team to achieve a shared understanding and to enable the

command team to control the incident through sectorisation and clear, visible lines of command.

In addition, the recording of such information facilitates effective post incident review, whether

by internal debrief processes or wider external scrutiny, such as that currently being undertaken

by the Grenfell Tower Inquiry.

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185 It is noted that the Grenfell Tower fire was beyond the experience of those who attended the

incident. Such was the extremely dynamic nature of the incident, it is likely this impacted on the

recording of decisions, objectives and the tactical plan that might ordinarily be expected at an

incident. In addition, the reported inoperability of the Command Support System (CSS) during

the incident may have been an additional factor in the absence of effective recording.

Recommendation 7 - The Brigade should consider how it can most effectively raise awareness of

and reinforce the requirements of PN 828 ‘Recording decisions at incidents’.

Key observation 3.6 : Difficulty in confirming who was being rescued or self evacuating

from the building and from where created difficulty in maintaining accurate records to

inform the search and rescue operation.

186 Many witnesses working at the Bridgehead described in evidence the challenge of accurately

gathering information about persons self evacuating or being rescued from Grenfell Tower. A

number of factors appear to have impacted on the ability to gather this information, including

casualties suffering physical or psychological trauma and communication issues.

187 Lack of information about where a casualty had been rescued or self evacuated from impacts

on maintaining a search and rescue plan that reflects the changing circumstances and priorities of

the incident. Similarly it can impact on wider situational awareness and the ability to evaluate

progress of search and rescue operations and subsequent reporting on progress to others.

188 At the Grenfell Tower fire, it is observed that these challenges, combined with the movement

of residents within the building, created circumstances that made it extremely difficult to ascertain

which flats identified in FSG calls were actually clear of occupants because either, the occupants

had self evacuated, had moved to a different location or had been rescued from elsewhere in the

building. These challenges could have potentially led to taskings to individual flats being

duplicated, impacting on resource utilisation or crews not being tasked to a flat because

inaccurate information suggested the occupants had been rescued or self evacuated.

Actions by the Brigade since the fire

189 It is noted that the Brigade has been reviewing PN 790 ‘Fire survival guidance’ and other

associated policies and evaluating procedures with Brigade Control and operational staff to

deliver effective service improvements in this area. Further details of this work are provided in

paragraphs 275 – 277.

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Recommendation 8 – Whilst it is recognised that the volume of FSG calls experienced during the

Grenfell Tower fire and the information associated with those calls was unprecedented, it is

recommended the Brigade considers the issues carefully to ascertain if any measures can be

implemented to address this matter.

Key observation 3.7 : Operational Discretion was adopted for the incident but it was not

formally recorded in accordance with Brigade policy.

190 Due to the fast-moving and varied nature of fire service operations, it is not possible for the

Brigade to provide explicit guidance that will satisfactorily cover all situations. On the rare

occasion that operational guidance does not meet the needs of the incident, ICs can adapt or

move away from an operational policy where this is necessary and justifiable in terms of risk

versus benefit. The decision to move away from operational policy is known as ‘operational

discretion’ and should be based on ‘professional judgement’ enabling the IC to make calculated

decisions about the course of action appropriate in the circumstances.

191 The use of operational discretion must be recorded as soon as practicable at stated in PN 828 –

‘Recording decisions at incidents’. The policy states that where a decision is made to carry out

actions that amend or change a current operational procedure, this needs to be recorded in a Key

Decision Log (KDL) and a risk assessment of the proposed activity needs to be undertaken and

recorded. The risk assessment must show the additional hazards and the associated risks that

have been identified and that appropriate control measures are being implemented before any

action is taken. This can be recorded on either the CSS or, if not available, on a KDL pad which

are provided on all CUs.

192 Two training packages covering ‘Recording decisions at incidents’ are available on the London

Fire Brigade / Babcock Training ‘Big Learning’ portal. One is aimed at station based personnel and

the other at senior officers.

193 The dynamic nature of some incidents may mean that it is not possible for a decision log to be

started immediately. However, key decisions are to be recorded as soon as reasonably practicable

using the KDL form, or on the logging facility within CSS.

194 As discussed under key observation 3.5 there was no decision log started for the incident until

02:47hrs although the incident was necessarily operating outside of the Brigade’s policy

framework, an example being crews deployed above a known fire situation without firefighting

media.

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195 Once the decision log is started it records a number of decisions that move outside of policy

but there is no evidence, at the time of writing, that a risk assessment identifying the additional

hazards and associated risks or the appropriate control measures is recorded.

196 See recommendation 7.

Theme 4 – Operations

Key observation 4.1: The Brigade had limited means to fight an external façade fire

resulting from the non compliance of the installed external cladding system with the

requirements of Regulation B4(1).

197 The response to fires in high rise premises is predicated on internal firefighting and supported

by building regulations which provide for firefighting facilities within such buildings, including

protected shafts, firefighting lifts, dry rising mains and internal compartmentation.

198 In his expert report for the Inquiry, dated March 2018, Mr Colin Todd noted that building

regulations state ‘the external walls of a building shall adequately resist the spread of fire over the

walls and from one building to another, having regard to its height, use and position of the

building’. Mr Todd goes on to observe ‘that whilst the dynamics of fire, can potentially, result in

the external spread of fire from one flat to the flat immediately above, fire spread significant

beyond such an extent would demonstrate a failure to comply with Requirement B4(1) of

Approved Document B’.

199 In respect of external firefighting capability, the Brigade has 11 frontline aerial appliances,

which consist of three different types of vehicle: All three vehicle types have varying functions /

capabilities and achieve a range of heights from 22 to 32 metres. In optimum conditions the

turntable ladder has the maximum height reach of 32 metres, which is equivalent to the 10th floor

of a typical high rise premises and it is likely, in most circumstances, that a firefighting jet can be

applied as high as the 14th floor.

200 These vehicles were originally chosen, taking in to account factors such as the technology

available at the time of purchase, the ability to locate the vehicles within the Brigade’s fire station

estate, their operational capability and vehicular access in London’s streets.

201 In advance of the arrival of an aerial appliance or if there is insufficient access to deploy an aerial

appliance, handheld jets and / or ground monitors can be deployed to provide an external

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firefighting capability. However the reach of any such firefighting jet is limited by a number of

factors, including but not limited to water flow, pressure, proximity to the fire.

202 Grenfell Tower did not have an aerial appliance included on the PDA for the premises at the

time of the fire. The nearest aerial appliance to Grenfell Tower is located at Paddington fire station

and it is noted this was the appliance (A213) mobilised in response to the first request for an aerial

appliance.

203 Having examined the incident log and noted a travel time of 12 minutes from Paddington to

Grenfell Tower and assumed a minimum of 15 minutes to get the appliance sited and working, it

is likely that even if A213 had been mobilised at 00:55hrs as part of the PDA for the premises, the

external fire would have been near if not past the reach of the appliance’s water monitor.

204 It is notable that access issues meant that no aerial appliance was able to operate on the north

or west elevations of Grenfell Tower. Operations on the south elevation were restricted by the

Grenfell walkway and the grassed area on the east elevation was not identified as suitable for

positioning a large aerial appliance albeit a aerial appliance was set up on this area after the crew

risk assessed that the recent period of hot weather had resulted in the ground being firm enough

to support the weight of the aerial appliance.

205 It is clear from documentary evidence that a water jet was directed intermittently at the east

elevation of Grenfell Tower between 01:15 and 01:25hrs before the crew ceased this activity and

returned to their appliance to rig in BA sets at around 01:28hrs. Attempts at external firefighting

were also made from the kitchen window of flat 16 once the original fire had been extinguished.

This was undertaken at significant risk by crews leaning out of the window space and directing

the jet at the flames above. Ultimately this initial external firefighting was not successful and

flames had reached the 23rd floor by 01:30hrs. Dr Lane concluded that it was not possible for any

handheld jet to reach beyond the 7th floor.

206 Further external firefighting was carried out on the east elevation from around 01:43hrs by a

ground monitor and by a turntable ladder, A213, until 02:07hrs when it was housed and re-

located due to falling debris. It was re-pitched and recommenced firefighting operations until

02:18hrs when it was again housed and moved under the Grenfell walkway due to falling and

burning debris.

207 Whilst external firefighting operations were improvised on all four elevations of Grenfell Tower

and Dr Lane noted there is a strong correlation between the floors to which water was applied

and the lack of external fire damage to these floors, it is recognised that the Brigade did not have

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the capability to apply water effectively to the exterior of the building above the 14th floor. It is

also noted that due to access restrictions, an aerial was unable to operate on the north and west

elevations and therefore water could only be applied up to the seventh floor on these elevations.

208 Dr Lane provided an opinion in her 5th November 2018 report that ‘it is not acceptable to

expect the fire and rescue service to mitigate the risk posed by combustible external wall

construction in high rise residential buildings, as there are so many reasons why that is not

feasible’.

Actions by the Brigade since the fire

Aerial appliances

209 At the time of the fire, the Brigade was finalising the procurement of 15 state of the art

articulating head 32m turntable ladders to replace its existing aerial fleet. Partially in response to

the Grenfell Tower fire and the new risk presented by clad buildings, the Brigade modified its

procurement plan to incorporate three 64 metre turntable ladders. These extended reach aerial

appliances will be strategically located across London to complement the standard aerial fleet.

Deliveries of new fleet of aerial appliances, built by Emergency One Limited, are scheduled to

commence in January 2020 for the 32 metre variant and in July 2020 in respect of the 64 metre

model.

Pre Determined Attendance (PDA)

210 As a result of the Grenfell Tower fire, and whilst awaiting the outcome of the MHCLG work into

cladding on high rise buildings, the Brigade implemented an interim change to the PDA to all high

rise buildings. This revision took effect from 22nd June 2017 with five fire engines, one aerial

appliance and the standard officer complement for a five pump fire being mobilised to any high

rise fire related incident.

211 In addition to the above, and as a result of the findings from the Government’s series of fire

safety tests of cladding and insulation combinations undertaken by the Building Research

Establishment, the Brigade made a further interim revision to the high rise PDA starting from 10th

August 2017. From this date when Brigade Control receives multiple calls (four calls or more) to a

residential high rise premise the PDA now includes eight fire engines and one aerial appliance.

Where the fire is reported to Brigade Control as involving the outside of a clad building the PDA

is further increased to ten fire engines and one aerial appliance (if the aerial appliance hasn’t

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already been despatched). When this increase in resources is made the standard officer

complement for an eight and ten pump fire is also mobilised.

Key observation 4.2 : Extensive breaches of compartmentation resulted in simultaneous

serious fires on multiple floors, impacting on the Brigade’s operational response.

212 The external fire experienced at Grenfell Tower was significant in terms of its scale and by the

rapidity of the spread and precipitated fires internally on multiple floors.

213 The premises was provided with a number of active and passive fire safety measures which

were intended to create a layered safety system intended to provide the means for an early

internal firefighting intervention. This is achieved by providing the means to limit fire and smoke

spread from a dwelling fire and create the high degree of compartmentation necessary to support

the ‘Stay Put’ strategy in a high rise residential premises.

214 Once the fire was established within the rain screen cladding system the fire safety measures

provided within Grenfell Tower were required to perform during an event not considered by

Building Regulations – a multi storey fire.

215 Dr Lane in her report, dated 5th November 2018, concluded that ‘The high degree of

compartmentation had suffered its primary failure, caused by the fire spreading through the rain

screen system’.

216 Professor Jose Torero in his expert report, dated 23rd May 2018, states ‘Firefighting protocols

for response to high rise building fires are intimately linked to a single floor fire. Furthermore, for

residential buildings, the firefighters should find, on arrival, a single unit fire’.

217 In practical terms, the failure of the compartmentation resulted in the Brigade facing and being

required to mitigate a number of significant and linked fire events, spread across multiple floors.

As described by Professor Torero, the firefighting provisions do not anticipate fire spread

affecting multiple floors and as such the water supply provided through the dry rising main is

predicated on a single unit fire event and, and as such, is only required to provide two or three

firefighting jets.

218 The impact of this was that the Brigade was unable to undertake simultaneous firefighting on

multiple floors to extinguish or control the fires. The deteriorating conditions within the lobbies

and stairwell resulting from these fires affected the ability of residents to self evacuate from the

building and hindered the Brigade’s attempts to effect rescues.

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219 In order to progress the search and rescue operations, it was necessary to deviate from

Brigade’s operational policy and commit firefighters above fire situations and into hazardous

environments without firefighting media.

220 Compliance with the Brigade’s operational policy would have resulted in a limited or no search

and rescue operation above the fourth floor, so commanders took what must have been a difficult

decision to continue operations by applying operational discretion.

Actions by the Brigade since the fire

Provision of water

221 The Brigade is currently reviewing existing solutions and undertaking further research into the

practical water pressures and flow rates that can be achieved at the maximum height of dry rising

mains, particularly those premises built when dry rising mains were permissible up to 60 metres.

This work is aimed at identifying if the Brigade’s current hose equipment and pumping

capabilities are able to provide optimum fire fighting jets at the maximum height of a dry rising

main. This research will involve practical testing at a number of residential high rise premises with

similar characteristics to Grenfell Tower.

High rise firefighting policy (PN 633)

222 PN 633 ‘High rise firefighting’ and the associated training materials have been the subject of an

extensive review by the Brigade’s OPA department. The revised policy is currently out for

consultation with the Brigade’s Heads of Service. It is also being extensively consulted on with the

two main Representative Bodies; the Fire Brigades Union (FBU) and Fire Officers Association

(FOA).

National Operational Guidance

223 The Brigade is also supporting the development of NOG for high rise fire fighting following the

Grenfell Tower fire. Two immediate issues were identified by the Grenfell Tower fire ‘safety and

learning’ investigation;

rapid fire spread taking place at the early stages of an incident and well before the

expectation of when compartmentation of a building would normally be compromised, and

how Fire Survival Guidance (FSG) calls are managed nationally when this type of call is passed

to another fire and rescue Control.

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224 Both issues have been communicated to the Fire Central Programme Office, where the Brigade

have worked closely with the NOL Secretariat. This has produced a series of recommendations.

NOLUG

225 These recommendations have resulted in a number of national ‘Action Notes’ being published

through the NOLUG forum. These include:

An Action Note sent to ‘Skills for Justice’ (the sector skills council for the fire and rescue

service) with a recommendation for the review of the National Occupational Standards

(NOS), with a purpose of ensuring relevant knowledge and understanding of building

construction, fixed installations, fire science and fire engineered solutions that complement

NOG – ‘Fires in buildings’;

An Action Note to all fire and rescue services in the UK highlighting the existing requirements

under the NOG control measures: 'Produce a risk management plan' and ‘Site Specific Risk

Information (SSRI)’, in reference to high-rise premises designed or constructed in a way that

may result in rapid fire spread. The note states that the National Fire Chiefs Council (NFCC)

support the approach of fire and rescue services determining their PDA for specific incident

types on the basis of their own operational risk assessment (ORA). Each ORA will be

cognisant of the need to achieve the appropriate speed and weight of attack;

An Action Note to NOG recommending a number of hazard and control measures relating to

rapid fire spread and appropriate provision for fire survival guidance has also been issued.

NFCC Simultaneous evacuation guidance

226 The Brigade also provided significant support to produce the NFCC publication ‘Guidance: To

support a temporary change to simultaneous evacuation strategy in purpose-built blocks of flats’9

for owners and persons / organisations responsible for buildings fitted with Aluminium

Composite Material cladding. This guidance was published in May 2018 and superseded an

earlier version published in October 2017. The guidance has been appended to this report as

Appendix F.

9 https://www.nationalfirechiefs.org.uk/Simultaneous-evacuation-guidance

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Key observation 4.3 : The building behaved in an unpredictable manner beyond the

experience of the Brigade.

227 The fire at Grenfell Tower originated in flat 16 on the fourth floor having started in an electrical

appliance. The evidence of the Inquiry experts identified that the building owners, Royal Borough

of Kensington and Chelsea (RBKC), had declared a ‘stay put’ strategy for the building which was

confirmed in its most recent fire risk assessment.

228 The ‘stay put’ strategy documented in guidance has been a principle of building design since

the 1960s and works on the assumption that residents are safe to stay in their flats unless directly

affected by fire, heat or smoke whilst the fire service extinguishes the fire. That principle is

founded on the building being constructed to provide a series of fire resistant compartments (the

flats), one or more protected means of escape, and fire safety measures to support internal

firefighting to ensure the fire in the compartment of origin can be extinguished before it spreads

beyond that compartment.

Behaviour of the external fire

229 The fire in the compartment of origin was extinguished at 01:21hrs but had breached the

kitchen window on the east elevation of Grenfell Tower. This, in itself, is not an usual event and

the Brigade and its operational personnel have experience of this situation. More unusually, the

fire emanating from the window ignited materials within the rain screen cladding system installed

on the original external walls of the premises and proceeded to spread vertically.

230 The Inquiry expert, Mr Colin Todd states in his report, dated March 2018 ‘whilst the dynamics

of fire, can potentially, result in the external spread of fire from one flat to the flat immediately

above, fire spread significant beyond such an extent would demonstrate a failure to comply with

Requirement B4(1) of Approved Document B’.

231 The resulting fire continued to spread vertically, reaching the top of the building by 01:30hrs.

The fire then proceeded to spread laterally in both directions, assisted by the presence of an

architectural crown, whilst causing burning droplets to create further fires within the cladding

below, resulting in what appeared to be a diagonal fire front burning laterally in both directions on

the east elevation.

232 At 01:42hrs, the fire had reached the north east corner of the building and proceeded to

continue to spread laterally across the north elevation. At 02:25hrs, the second flame front had

reached the south elevation and continued to spread. At 02:51hrs the first flame front had

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reached the west elevation and by 04:44hrs, all four elevations of the building were fully involved

in the external fire.

Training on high rise external fires

233 A number of Brigade witnesses stated they had no specific training on fires in cladding. Many

witnesses explained that it was their expectation that exterior of a building could not burn in the

way experienced at Grenfell Tower but did demonstrate an understanding of the ‘coanda’ effect

referenced in GRA 3.2 and PN 633.

234 A number of witnesses provided evidence that their experience and expectations of external

fires on high rise buildings involved fires in netting provided for safety purposes on scaffolding

around buildings under construction or refurbishment, or involved fires on the balconies of such

premises .

Penetration of the fire internally

235 Internal penetration of the fire through open or failing windows subsequently caused internal

fires on multiple floors which in turn spread further as a result of compartmentation issues.

236 Evidence from witnesses suggested that the extent of any internal fires was not clear to

command officers until some time after 02:15hrs, although some witnesses acknowledged the

likely presence of smoke within the building as indicated by the FSG calls.

GRA 3.2 and PN 633

237 Following the Lakanal House fire and a number of other significant fires in high rise premises,

GRA 3.2 was reviewed and 15 new hazards were incorporated and others were enhanced with

additional information in the 2014 version. The new hazards included make explicit reference to

the fact that fire and smoke can spread in an upward, downward and horizontal direction and in

ways that can be less predictable than in other building types. A new hazard was identified with

regard to the risk of fires occurring simultaneously on multiple floors and explicit reference is

made to the fact that falling debris has the potential to cut hose lines and interrupt water supplies

during firefighting.

238 The Brigade’s PN 633 was reviewed following the publication of the revised GRA 3.2 and

generally reflects the information contained within the GRA. Notably PN 633 makes reference to

the fact that fire and smoke can travel in any direction and the downward travel, in particular, can

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have an adverse impact on fire service operations. It also notes the potential for fires on more than

one floor.

239 A full explanation of the development of both documents, their relationship and any

differences is set out in the Brigade report ‘National guidance and London Fire Brigade

operational policy for fighting fires in high rise buildings’ is appended to this report as Appendix

E.

240 The Brigade has previously addressed unusual fire spread in two training interventions,

specifically, the Lakanal House case study in 2014 and the High Street, Barkingside case study in

2012, completion of which were mandatory for all operational personnel. Additionally, unusual

fire spread was addressed in two issues of Operational News, issues 20 and 28, dated November

2011 and December 2014 respectively.

241 The extent to which, and when, the Brigade’s officers recognised the significance of and the

potential consequences of the external fire and the unexpected fire and smoke spread within the

building will be a key area of investigation in Phase 2 of the Inquiry.

242 An effective recognition of both matters was inextricably linked to any consideration of the

requirement for a full simultaneous evacuation of the building.

Actions by the Brigade since the fire

243 It is noted that the Brigade has commissioned a comprehensive review of its training provision

following the major incidents that the Brigade responded to in 2017. It is being undertaken by an

independent consultancy company, Ribband Star Limited, and is expected to take six months to

complete.

244 The purpose of the review is to provide an objective baseline of organisational awareness of

operational training including Control training and support key organisational priorities and

provide an evidence base for continuous improvement.

245 The review will examine four key areas:

Acquisition of Skills/Knowledge

o An assessment of the effectiveness of all operational training provided by the

Brigade’s third party contractor, Babcock Training Limited.

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o An assessment of the effectiveness of Brigade Control training provided by the

Brigade’s Control training team.

Maintenance of Skills

o To review systems in place – and those proposed for Developing and Maintaining

Operational Professionalism (DAMOP) – to ensure that maintenance of skills activities

are undertaken at all operational levels including Control training and that assurance

mechanisms are in place to evidence that the service is maintaining an operational

readiness to an appropriate professional standard.

Routine testing/quality assurance

o To provide an assessment of quality assurance processes in place within the Brigade

and Babcock Training Limited ensuring that assurance processes are fit for purpose.

Future proofing

o To analyse whether the current training provision (acquisition and maintenance) is risk

based and is adaptive to future demands.

Recommendation 9 - The Brigade should consider to what extent recognition that a building is

behaving unpredictably in fire is addressed in policy and training.

Key observation 4.4 : The building’s single escape route was significantly compromised by

the products of combustion from an early stage of the incident.

Protected lobbies and stairs

246 The means of escape to the final exit at Grenfell Tower was a single staircase provided with a

protected lobby at every storey. A smoke control system, an active measure, was provided to

protect each lobby and in doing so protect the single escape stair.

247 The evidence from witnesses and the Inquiry’s experts indicate that the active and passive fire

protection measures in the lobbies and stairwell failed to perform adequately on the night of the

fire and became compromised by heat and smoke from some time between 01:21 and 01:40hrs.

248 The failure of the protected lobbies is attributed by Dr Lane to flat front doors failing to control

the spread of fire and smoke from flats into the lobbies and vice versa. This is attributed to a lack

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of performance, initially identified by a fire resistance test undertaken by BRE Global, on behalf of

the MPS, on a sample door of the type fitted to the majority of flats within Grenfell Tower.

249 Evidence available to date indicates there is a close correlation between the progress of the

vertical fire spread and the presence of smoke in lobbies. For example, smoke is reported in 13 of

20 lobbies between 01:19 and 01:38hrs, increasing to 15 out of 20 lobbies by 01:58hrs. By

02:38hrs, smoke is reported in 19 out of 20 lobbies with severe temperatures on floors six to 10.

250 British Standard 9991:2015 states ‘Whilst a simultaneous evacuation is normally not necessary,

there will be some occasions where operational conditions are such that the fire and rescue

service decide to evacuate the building. In these situations, the occupants of the building will

need to use the common stair, sometimes whilst firefighting is in progress. As such, the measures

in this British Standard for the protection of common stair are designed to ensure that they are

available for use over an extended period.’

251 Dr Lane has further noted in her report in relation to the stair doors ‘I observed no fire damage

in the stairs consistent with the total failure of a stair door, allowing fire spread onto the stairs’ but

does note ‘the non-compliances I have identified would have contributed to the failure to prevent

the spread of smoke to the stair’.

Mechanical smoke control system

252 A replacement mechanical smoke control system was installed in Grenfell Tower during the

2012-2016 refurbishment, its purpose being to control the amount of smoke entering a lobby and

therefore reducing the risk of smoke spread to the protected stair. The smoke control system was

intended to operate on one floor only, as per the requirements of Approved Document B, and

was not expected or designed to operate on multiple floors simultaneously.

253 A smoke detector was present outside flat 16, the fire compartment of origin, and this detector

should have activated the smoke control system on the fourth floor. There are no reports of

smoke in any other lobby at this time. Evidence from residents report thick black smoke entering

the stairs from the lobby on the fourth floor, indicating the smoke control system was not

operating as designed.

254 As detailed in paragraph 249, the failure of the mechanical smoke control system to operate as

designed contributed to the extensive spread of smoke into a number of lobbies and the

protected stair as the fire developed.

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Positive Pressure Ventilation

255 The Brigade has a limited Positive Pressure Ventilation (PPV) capability incorporated within its

Special Operations capabilities but it is not, at present, a frontline capability. PPV can be utilised

to undertake the planned and systematic removal of heat and smoke from the structure on fire,

and their replacement with a supply of fresher air in order to facilitate other firefighting priorities

and is used extensively by other UK fire and rescue services.

256 The IC requested PPV at 02:57hrs and it arrived on scene at around 04:00hrs. An attempt to

use the PPV at around 05:00hrs to improve conditions in the ground floor lobby was unsuccessful

and actually worsens the conditions, so its use was discontinued.

Challenges presented by the conditions

257 The circumstances described above created challenging conditions for anyone seeking to

evacuate from the building and for firefighters attempting to rescue those trapped within the

building. In some instances firefighters were forced to make decisions, having reached a

resident/s, as to the viability of moving a person through conditions that may have been

considered untenable in terms of saving life and were often changing second by second.

258 In some cases, firefighters opted to leave residents in situ or move them to safer areas to avoid

the risks presented by the untenable conditions. On one occasion around 02:00hrs, a crew

utilised spare firefighter BA sets, obtained from the bridgehead, to rescue a mother and daughter

from ninth floor. This improvised method of rescue was not replicated during the remainder of

the incident but remains a commendable example of the ingenuity of firefighters.

259 Those conditions described above may have impacted on the feasibility and potential success

of any full evacuation from the building, owing the very real but unquantified danger that those

evacuating may have been overcome by the conditions encountered in the lobbies and stairwell,

assuming that residents could have been contacted to advise on evacuation. It is noted that there

was no central alarm system fitted to Grenfell Tower, nor was there any regulatory requirement

for such a system.

Actions by the Brigade since the fire

260 Recognising the challenges that Brigade officers faced in respect to the catastrophic failure of

the Grenfell Tower building, in particular that associated with the protected single staircase which

became compromised by heat, smoke and fire at a very early stage of the incident, the Brigade

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has undertaken research and procured fire escape hoods (also commonly referred to as smoke

hoods).

Fire escape hoods

261 Fire escape hoods are designed to be used easily by members of the public where they need

rescuing through smoke filled environments, such as those experienced at Grenfell Tower. They

provide members of the public with up to 15 minutes of protection from four of the main fire

gases and can be worn by conscious and unconscious persons. If more than 15 minutes of

protection is required then another hood can be given to each wearer. Firefighters will be able to

offer a hood to those being rescued and they can also be used to protect those who are not able

to escape easily, such as the elderly or those with limited mobility.

262 The fire escape hoods have been issued to all frontline appliances across the Brigade and are

carried on the Brigade’s standard and extended duration BA sets. This provides a total of 649

hoods on frontline appliances and gives firefighters and officers a new tactical option should a

similar building failure occur in the future.

263 Since their introduction and at the time of writing, the fire escape hoods have been used on 8

occasions to protect 16 members of the public from hazardous conditions created by the

products of combustion.

PPV and PN 833 – Tactical ventilation

264 The Brigade has extensively reviewed PN 883, Tactical Ventilation as of the 4 April 2018,

reiterating that the PPV equipment and capability is currently under evaluation. They have also

added Appendix 1 to PN 883,which explains the functionality and capabilities of PPV.

265 In addition, the OPA department has recently initiated a PPV project group. The aim of this

group is to deliver level 1, defensive ventilation, which is carried out away from the fire, or after

the fire is extinguished, to remove heat and smoke, particularly to improve access and escape

routes in areas of the building not directly affected by fire. The aspiration in phase one of the

project is to place 10 PPV into operational service at 10 strategic locations to provide the Brigade

with a defensive ventilation operational capability. The Brigade has allocated £350k to evaluate

and deliver this part of the project.

266 The Brigade still retains two sets of PPV reserved specifically for its Special Operations

capabilities and this equipment is now available on two specialist vehicles; one for responding to

terrorist incidents and the other on a vehicle carrying an ultra high pressure lance used to

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suppress fire conditions, particularly in situations when it not possible to enter a compartment on

fire.

Future firefighting technology

267 The Brigade is also evaluating the introduction of other new firefighting technologies for

frontline appliances including the ultra high pressure lance and misting systems. Both have

identifiable benefits for firefighter and public safety in many operational scenarios.

Key observation 4.5 : Number of FSG calls and the resulting volume of information

significantly exceeded the expectations of Brigade policy and training.

268 Following the Lakanal House fire in 2009, the Brigade reviewed its procedures for managing

fire survival guidance calls and introduced PN 790. In addition, it introduced Forward Information

Boards to record key information at a range of different incident types and PN 820 to support

their use. At the Lakanal House fire, crews recorded FSG information on walls at the Bridgehead

and it was identified that this risk critical information could be lost if the Bridgehead was forced to

relocate due to deteriorating conditions.

269 The first of 152 calls from persons located within Grenfell Tower was received by Brigade

Control at 01:21hrs and the volume increased exponentially to an extent that British Telecom

began transferring calls to other fire and rescue service Control rooms, namely North West Fire

Control, Essex FRS, Merseyside FRS, Surrey FRS, and Kent FRS. There is also evidence that calls

were received by other agencies during the course of the night including the MPS and London

Ambulance Service (LAS). The last call received from someone inside Grenfell Tower was

received at 04:33hrs.

270 The evidence adduced in Phase 1 of the Inquiry suggests that there were a number of

communication channels for FSG information established from Brigade Control to the incident

ground during the first two hours of the incident.

271 On the incident ground as the volume of FSG calls intensified, the process of transferring

information to the Bridgehead became more complex as additional officers and communication

systems were introduced incrementally into the system. Evidence from witnesses indicated that

various elements were working independently without knowledge of the other.

272 Around 02:00hrs, an FSG coordinator was appointed to manage the information and allocated

CU7 for this purpose. All FSG information held on CU8 was transferred to CU7. Once CU7 was

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set up and established, a message was sent to Brigade Control at 02:22hrs advising that all FSG

information should be passed to CU7.

273 In the fire sector, crews, as they had at the Lakanal House fire, resorted to recording FSG

information on walls in all three locations where the Bridgehead was set up. It is not clear if the

use of multiple Forward Information Boards (FIB) was considered to manage the volume of

information. Information was photographed on a mobile phone when the Bridgehead was

relocated to ensure it was captured and re-recorded in the new Bridgehead location.

274 It is clear that the Brigade’s policies and training did not anticipate the volume of the FSG

information and the rapidity with which it was received. Evidence from witnesses suggest that

incidents or exercises involving more than three or four FSG calls are extremely rare.

Actions by the Brigade since the fire

275 The Brigade’s OPA department is currently reviewing PN 790 and the extant processes used to

manage FSG calls to identify improvement. To date, five exercises have been conducted with

Brigade Control to identify any resourcing difficulties and the interface between Brigade Control,

CU, and the Bridgehead. The exercise used was based on a high rise incident with FSG phone

calls into Brigade Control from members of the public (role played by firefighters).

276 Any identified improvements arising from an evaluation of these exercises will necessitate

further testing and consultation with Representative Bodies before they can be incorporated into

policy and training solutions identified and implemented. This is likely to take some months and

no clear outcomes are expected before the end of the summer 2019.

277 The Brigade’s CU replacement programme may also offer a longer term technical solution

which delivers further improvements.

Key observation 4.6 : Operational personnel were required by circumstances to provide

fire survival guidance to residents, a task not anticipated by policy or training.

278 During the course of the Grenfell Tower fire, firefighters were required to provide fire survival

guidance to members of the public in a number of ways.

279 There are a number of instances where BA crews, having reached the location they were

tasked to, had to make calculated decisions on the tenability of conditions within the building that

were often changing by the second, to determine whether it was feasible to evacuate the persons

trapped. Crews would have had minimal situational awareness of conditions away from their

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immediate location and radio communications issues meant they could not seek information on

conditions from others. Similarly, issues with radio communications resulted in crews being

unable to seek advice or support from others on the most effective course of action.

280 When crews determined the risk arising from an attempted evacuation was too great, they

were then required to provide instructions and advice to keep residents safe until a subsequent

rescue attempt could be made.

281 Outside Grenfell Tower, there were a number of occasions where firefighters and officers were

required to talk to trapped residents directly on the phone or indirectly through family or friends.

On some occasions, residents were encouraged to ring 999 to ensure their information was

recorded accurately and transferred effectively.

282 On other occasions, firefighters felt a moral duty to help and engaged to provide advice and

support directly to residents on the phone. In one instance, a firefighter stayed on the phone for a

considerable length of time until the call dropped out when the resident is likely to have become

overcome by smoke.

283 The issues described above are not anticipated by policy and firefighters and officers have

received no specific training in relation to this situation, other than the more general knowledge

and understanding of fire survival guidance and the ‘stay put’ strategy.

Actions by the Brigade since the fire

284 The Brigade’s OPA department are considering this issue within its wider review work around

PN 790 and the systems and processes related to FSG calls, as detailed in paragraphs 275 – 277.

Key observation 4.7 : Operational crews had problems physically identifying floor

numbers in the stairwell.

285 Many Brigade witnesses involved in the search and rescue operation noted that it was difficult

to establish what floor they were on due to the lack of suitably visible markings in the stairwell

indicating the floor number. This may have created delays to the search and rescue operations as

crews had to periodically enter lobbies to identify on which floor they were located by checking

numbers of flat front doors.

286 In addition to potential delays in getting to the floor or flat that they had been tasked to, this

issue resulted in crews having to enter lobbies unnecessarily, in order to identify which floor they

were on. Often, these lobbies were significantly involved in fire and / or heavily smoke logged

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and many of those crews did not have firefighting media available to them, owing to water supply

issues arising from the capacity of the DRM. This placed them at greater risk than was entirely

necessary.

Actions by the Brigade since the fire

287 The Brigade has suggested the requirement for adequate markings within buildings to indicate

floor levels should be more effectively addressed in building regulations as part of its

comprehensive response to the government’s consultation on the technical review of Approved

Document B (ADB).

Key observation 4.8 : Some elements of the BA operations during the Grenfell Tower fire

were not fully aligned to the Brigade’s operational procedures set out in PN 466.

288 The Brigade’s BA operations are governed by a procedural framework set out in PN 466

‘Respiratory protective equipment (RPE) – BA operational procedures’. This PN is supported by

nine additional PNs addressing technical specifications, BA operations for specific incident types,

ancillary equipment, personal protective equipment and radio communications equipment.

289 The purpose of BA and associated control procedures is to reduce the risk of respiratory

discomfort or injury to personnel and provide safe systems of work when BA is used. It is

important that personnel who may be required to wear BA or undertake entry control duties

understand and properly implement these procedures at all times.

290 At any incident, the IC is responsible for ensuring that RPE is worn whenever there is a risk of

personnel suffering respiratory discomfort or injury. Where any doubt exists as to the presence of

a respiratory risk, the IC will give instructions for RPE to be used. BA is the default level of

respiratory protection for fires and other incidents presenting an acute respiratory hazard.

291 PN 466 has been produced with regard to the following RPE legislation and approved codes of

practice as well as other health and safety legislation:

National Operational Guidance Programme – Foundation for Breathing Apparatus.

National Operational Guidance – Breathing Apparatus Training Specification.

Control of Substances Hazardous to Health Regulations: 2002.

Ionising Radiations Regulations: 1999.

Control of Lead at Work Regulations: 2002.

Control of Asbestos Regulations: 2012.

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Dangerous Substances and Explosive Atmospheres Regulations: 2002.

Confined Spaces Regulations: 1997.

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations: 2013.

292 BA operations are identified as a core skill for firefighters and as such wearers are subject to

regular maintenance of competence checks undertaken on station, known as ‘Best Practice

Assessments’.

293 In addition, firefighters have to complete BA refresher training provided by Babcock Training

annually at one of its Centres of Excellence.

294 The Babcock Training / London Fire Brigade learning portal also provides seven online training

packages covering all elements of BA equipment and operations.

295 It is not intended to cover each occurrence in full within this preliminary report as investigations

are ongoing but a summary of each issue is provided below, together with information, where

appropriate, for the Brigade to reflect on when determining its response to this operational

learning.

296 The Health and Safety Executive (HSE) has acknowledged in its publication ‘Striking the

Balance’ that the application of health and safety law is challenging for fire and rescue services in

relation to some operational activities. It notes the following points which are considered relevant

and should be reflected on by the Brigade:

they have to send firefighters into dangerous situations in order to save lives when anyone

else would be seeking to get away from the danger;

there is often an unrealistic public expectation that firefighters will put themselves at risk even

when such risks outweigh any potential benefits to be gained;

many incidents firefighters face can develop at speed, some can develop in unexpected ways

– and firefighters may, from time to time, be confronted with situations outside their

experience;

they have to prepare individual employees to be able to make decisions in dangerous, fast-

moving, emotionally charged and pressurised situations, even when there may sometimes be

incomplete or inaccurate information about the incident;

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they have to respond to dangerous situations which are not of their own making - this is

different to most other sectors where it is the employer’s own business that creates the

hazards; and

they may not be able to control or mitigate some aspects of the working environment.

297 No BA emergency teams were formally established as detailed in PN 466 but the Brigade

should consider this in the context of the large number of BA wearers who were rigged and ready

for deployment in Grenfell Tower throughout the incident.

298 PN 466 states that wearers must withdraw from the hazard if both radio communications and

telemetry are lost between the Entry Control Point (ECP) and the BA team. Whilst there is

evidence that there were sustained radio communications issues and sporadic telemetry signal

issues, it is not clear at the time of writing if and when this occurred simultaneously and

investigations are ongoing. From the available evidence it is known that no personnel were

withdrawn from the hazard area by commanders as a result of radio and telemetry issues and no

BA team elected to withdraw for this reason.

299 A relatively small number of personnel were recommitted to the incident when there were

additional firefighters on scene who had not previously worn and were available for deployment.

It is not clear at the time of writing if those previously recommitted into the hazard area had the

sufficient rest and recovery periods detailed in PN 466. The policy states that rest and recovery

periods will only be shortened in exceptional circumstances i.e. to save a saveable life when no

fresh wearers are available.

300 Whilst it is apparent that fresh wearers were available, the dynamic nature of the incident, the

need to save life, and the individual responsibilities of personnel should be taken into account by

the Brigade when considering their response to this operational learning.

301 It has been identified that the maximum number of wearers for one Entry Control Board (ECB)

was exceeded during the early stages of the incident, meaning appropriate entry control

procedures and the recording of briefs, locations and actions, alongside the use of telemetry were

not always achieved.

302 Following the revision to the maximum number of wearers permitted under Stage 1 entry

control procedures to six wearers, this will increase the likelihood of exceeding the facilities of

one ECB and resources that will be required to establish Stage 2 entry control procedures earlier

in an incident where higher number of BA wearers are required.

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303 A number of firefighters booked into the ECP in accordance with PN 466 but did not don their

facemasks and ‘go under air’ until they reached a point in the hazard area that respiratory

protection became an absolute necessity. PN 466 makes clear that all personnel passing through

the ECP must be ‘under air’.

304 Despite BA Main Control being established, the majority of the BA teams that exited the

building did not return to BA Main Control for further instruction. The Brigade’s policy requires

the role of BA Main Control Officer, now a BA Sector Commander under the revised policy, to be

undertaken by a minimum role of a SM. The training requirements for the role of a BA Sector

Commander are not identified in any training framework for the role of a SM or above.

305 A number of firefighters exited the hazard zone past their ‘time of whistle’ and therefore

without the required safety margin of air remaining in their cylinders. There is one instance of a

firefighter leaving the hazard zone without his BA facemask and helmet, having abandoned both

after completely exhausting his air supply during his attempts to rescue a casualty from the

building.

306 There is no evidence that emergency exchange of air procedures were adopted to support

firefighters who were low on air whilst still in the hazard area.

307 Evidence has identified that there were occasions where briefs and debriefs lacked detail,

which led to areas of the building being searched on more than one occasion. Information such

as, areas that had been searched and numbers of people rescued from specific flats were not

accurately relayed. This was also compounded by residents and occupants of the building moving

to different flats and floors or attempting to self-evacuate following fire survival guidance.

308 A clear degradation factor that contributed to a lack of detail for some briefings was the amount

of information that was being communicated under high pressure conditions, which led to some

key information not being recorded appropriately, leading to tasks that were allocated to

subsequent BA teams being less effective. Accurate recording of briefs and debriefing would

have assisted subsequent allocation of tasks and identification of hazards. The Brigade had

previously published an article and associated training in its Operational News publication in

January 2012 covering the briefing and debriefing of BA teams.

309 A dedicated BA Comms Operative was not established until 04:00hrs although sufficient

resources were available. It is suggested that the Brigade reflect that there were radio

communications issues, most likely as a result of demand exceeding capacity, and therefore the

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ability for BA teams to communicate with the ECP was limited in any event. This is addressed in

more detail in Theme 6 – Communications.

310 ECB tripods were not used until approx. 06:00hrs. It is known that placing the ECB in the

provided tripod stand increases telemetry signal propagation.

311 A number of BA log books had been completed incorrectly on station and are illegible,

impacting on the post incident review. This issue is described more fully under key observation

7.3.

312 Evidence has identified that the deployment of working radio repeater and telemetry repeaters

was unsuccessful. The ultimate reason cannot be confirmed as to why they did not perform as

expected but it is evident that personnel’s knowledge and understanding of their deployment is

inconsistent. Currently only extended duration BA wearers are trained in the deployment of radio

repeaters, which is delivered on refresher training courses only.

Recommendation 10 - It is suggested the Brigade considers the extent to which policy, training and

human factors played a role in the control measure degradation identified in the preceding

paragraphs.

Actions by the Brigade since the fire

Data retrieval and analysis

313 Immediately following the fire, the Brigade downloaded the data from over 1200 BA sets and

100 telemetry boards to ensure it had captured all data that might be relevant to the incident. A

number of telemetry boards suffered extensive heat and water damage and were returned to the

manufacturer who were able to retrieve the required data.

314 The only data believed to have been lost is that where the electronic memory of a board was

overwritten due to insufficient capacity. This learning was communicated to the manufacturer

who has now increased the memory capacity of its telemetry boards to prevent a reoccurrence.

315 The data retrieved from both the BA sets and telemetry boards is complex and not easily

understood without the correct knowledge. The Deputy Head of the PEG has been seconded to

GTIRT since June 2017 to ensure all data is collated and analysed effectively to support the

internal investigation and assist external investigations by the Inquiry and the MPS.

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National Operational Guidance

316 The Brigade has engaged extensively with NOL Secretariat to reinforce its own understanding

of the observations identified above and to support the identification of degradation factors which

may cause control measures not to perform as expected. A report by the Secretariat outlining

findings and making recommendations for revisions to the Foundation for BA guidance has been

finalised and will be presented to NOLUG for consideration.

Respiratory health monitoring

317 The Brigade is currently working with University College Hospital to scope an independent

long term respiratory health study for staff who attended the incident to support those staff and

build a greater understanding of the long term impact of firefighting operations on respiratory

health.

Theme 5 – Brigade Control

Key observation 5.1 : The facilities at the Brigade’s fallback Control, located in Stratford,

did not fully replicate those at the primary Control in Merton.

318 The Brigade’s primary Control is located at Merton and it operates a secondary or fallback

Control, located at Stratford fire station to provide resilience to its control and mobilising function.

319 The Stratford facility is generally used during planned maintenance to the systems at the

primary location but can be stood up at short notice if the primary site is not able to operate for

any reason. The Brigade has established and well practiced procedures to fall back to the

secondary Control when required.

320 On the 14th June 2017, Brigade Control was operating at Stratford due to planned maintenance

at the Merton site. The secondary Control at Stratford is smaller than the primary site and images

illustrating the difference are contained within the report appended as Appendix B.

321 In general, the facilities at Stratford replicate those at Merton with the same integrated

mobilising and communications systems provided at both locations. On the night of the Grenfell

Tower fire the main differences were that the Stratford site did not have the facility to access the

Brigade’s Dynamic Cover Tool (DCT) or access the National Police Air Service (NPAS) downlink

imagery via the ‘heli tele’ system.

322 The DCT is a computer software application designed to assist Brigade Control to manage the

movement of appliances between locations during large incidents or periods of peak demand, in

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order to maintain operational cover across the geographical area the Brigade is responsible for.

The non-availability of the DCT on the night of the fire required an Assistant Operations Manager

(AOM) to manually manage the movement of appliances to maintain pan London fire cover. This

was a complex task, given the number of appliance movements required as the incident at

Grenfell Tower escalated, and it is testament to the knowledge and experience of the AOM

responsible that operational cover was maintained effectively.

323 The Brigade is unique in having a fixed ‘heli tele’ downlink and this is a legacy of its relationship

with the MPS Air Support Unit before it transitioned to NPAS. The fixed downlink is provided to

increase situational awareness and is available at the primary Control, Brigade Headquarters, and

on the CUs.

324 Whilst the facility was not provided at Stratford, it is noted from evidence, during Phase 1 of

the Inquiry, that on the night of the fire, the downlink had been withdrawn from external agencies

by NPAS and so CROs would have been unable to view in any event.

Actions by the Brigade since the fire

DCT and Heli-Tele

325 The DCT software application has now been installed at the Stratford site and is fully

functioning to assist staff to manage operational cover requirements when Brigade Control is

operating from the secondary facility. The heli – tele downlink is also now available at the

Stratford site.

326 As referenced in paragraph 164, the Brigade is also undertaking an operational trial of drone

technology to increase situational awareness during and reduce its reliance on support from

external partners such as NPAS.

Key observation 5.2 : FSG call information was not gathered and communicated in

accordance with PN 539, Appendix 3.

327 PN 539 states ‘The Brigade defines a Fire Survival Guidance (FSG) call as being a call to Brigade

Control where the caller believes that they are unable to leave their premises due to the effects of

fire, and where the Control Room Operator (CRO) remains on the line providing appropriate

advice until either the caller is able to leave by their own means, is rescued by the Brigade, or the

line is cleared’.

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328 There is specific guidance for CROs to follow when taking calls to fire situations in domestic

accommodation, where callers have indicated they are unable to leave their premises. This

guidance follows national guidance and employs the principles of Escape, Assist, Protect and

Rescue.

329 The following text is the relevant extract from Appendix 3 of PN 539:

Brigade Control advise callers to ‘Get out and Stay out’, however if a call is received from a High

rise building where Fire, Heat and Smoke are not affecting the caller, LFB would advise that:

You are usually safest to remain in your premises unless affected by fire, heat or smoke. If the

situation changes, you should leave your premises and dial 999, if you need further assistance.’

Should the caller be unable to escape, a RIF10 containing prompts are in place on the computer-

aided mobilising system to assist the CRO in:

Providing guidance to assist the caller to safety.

Provide timely and relevant information to the attending resources.

Provide reassurance to the caller that help and assistance is forthcoming.

The CRO will ascertain through initial questioning, the type of premises the caller is in and use the

link on the Reference Information File to take them to the appropriate area of information to use,

to assist the caller.

CROs will always use the four principles of Escape, Assess, Protect and Rescue to provide

guidance to these callers. Firstly by assisting the caller to help identify a safe, alternative ESCAPE

route for them to leave their premises. If this is not possible, then CROs are directed to ASSESS

the situation by asking the caller direct questions: Example questions are:

Do you know where the fire is?

What room are you in?

Is anyone with you?

CROs will begin to PROTECT the caller by providing current fire safety advice to attempt to keep

the caller safe. They are directed to reassure the caller and REASSESS the callers situation:

Example questions are:

10 Reference Information File

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Has that stopped the smoke coming in?

Let me know if the smoke gets thicker?

What’s happening now?

CROs will remain on the telephone with the caller and assist with RESCUE.

Other CROs and supervisory staff will assist the CRO carrying out the Fire Survival Guidance call

by ensuring all relevant information regarding the caller’s situation is passed via both the airwave

radio and via telephone when a CU is in attendance. Relevant information to be passed to the

incident ground includes:

Number of persons involved

Names if known (by telephone only, not by radio)

Condition of their location i.e. heavy smoke, thick smoke

Location of caller within premises

Callers proximity to fire

Latest FSG advice given by Control

Time of FSG call

330 From the evidence adduced in Phase 1 of the Inquiry, it is apparent that during a number of

FSG calls arising from the Grenfell Tower fire there were no proactive attempts to identify a safe

alternative escape route with the caller. During questioning on this matter by Counsel to the

Inquiry, one witness explained they would be expect persons living in residential high rise blocks

with a single stair would be familiar with their escape route. Another witness described the

volume of calls as being a factor and the need to prevent a queue of calls from building.

331 Counsel to the Inquiry also asked Brigade Control witnesses about efforts to assist callers with

assessing the situation. Those witnesses explained that their own situational awareness is limited

as they are remote from the incident and the callers themselves are generally best placed to

assess the conditions affecting them.

332 Witnesses also provided oral evidence that expressed the difficulties and risks associated with

directing those trapped to follow particular instructions like opening doors to check escape

routes, which may only serve to further deteriorate conditions in the location where persons are

sheltering.

333 It is noted that many residents expressed a reluctance to leave their properties even when

instructed to do so, because of the conditions outside of their flats. Control witnesses said that in

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those circumstances you have to believe the caller, who is best placed to observe the conditions

they are experiencing and assess the conditions they face if they attempt to leave their place of

relative safety.

334 This is reinforced by the evidence of one resident ultimately rescued by the Brigade but who

had earlier resisted all attempts by CROs to persuade him to evacuate the building. When

questioned by the Inquiry on why he had ignored the instructions from the Brigade, the witness

stated “Well ... I would have assessed again if I was in the condition to go out. But obviously she

would've taken a big responsibility to do so on her behalf, because she wouldn't know how bad

the conditions outside were. I knew, she didn't. She wouldn't know”.

335 He went on to state “Now let's say I would be convinced by this person to go out, and if

something had happened to me, how would that person feel if I had not made it out, basically? So

that's why I said, you know, I don't want to think of someone thinking, "Oh, because I gave him

that advice, look what happened to him". How would that person then live for the rest of their

life?”

336 This graphically illustrates the dilemma which CROs face in circumstances such as those

experienced at Grenfell Tower that even if they seek to explore with a caller the conditions

immediately outside their flats, they cannot know what the conditions may be beyond the

immediate vicinity when considering whether to advise residents to leave their flats. There always

remains a risk that they will be directing them into dangerous and potentially lethal conditions.

There were numerous examples in the evidence of rapidly changing conditions within the

building, by which smoke, toxicity and visibility changed minute by minute and often, second by

second.

337 There, of course, may come a time when the situation has deteriorated to such an extent that

escape remains the only viable option, whatever the risks involved. In those circumstances, it is

necessary for CROs to make every effort to encourage or even coerce callers into attempting to

escape. Evidence adduced in Phase 1 established that one CRO, during a particular FSG call, very

forcefully sought to persuade the caller to leave their flat, even graphically describing the

potential consequences if they did not.

338 It is noted from evidence that PN 539 directs CROs to stay on the line with callers until they are

rescued by the Brigade. Such was the volume of calls related to Grenfell Tower, CROs felt unable

to stay on the line in most instances due to the need to reduce the number of calls queuing in the

system, many of whom would have also been from residents trapped in the Tower.

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339 There are exceptions when CROs stayed on the call until the call dropped out which included

one call which lasted just under an hour and these calls proved to be particularly harrowing for

the CROs concerned. This is discussed in more detail under key observation 5.8.

340 Evidence from witnesses during Phase 1 demonstrated that the way CROs handled FSG calls

and provided advice to callers was predicated on the assumption that they would be rescued. The

Lakanal House fire in 2009 tragically demonstrated this is not always the case and prompted the

need for CROs to engage more fully in active listening to build a more complete picture of the

circumstances facing the caller.

341 A number of calls were received by Brigade Control in the early stages of the incident where

the callers, located on the upper floors of Grenfell Tower state there is smoke in their flats and / or

fire at the window. However the significance of this information is not recognised by the CROs

and with limited situational awareness, they did not reconcile the information to their

understanding of the incident.

342 One Brigade witness gave oral evidence to the Inquiry describing how they were unable to

comprehend that a caller from an upper floor was describing smoke, and even fire, in their

vicinity, when the fire was on the fourth floor.

343 The RIF details the information that should be recorded and communicated to the incident

ground. One notable omission from nearly all FSG information received by the incident ground is

the time the FSG call was received. This information is significant, particularly in circumstances

where the IC or responsible officer may need to prioritise the individual calls.

344 There were also limited examples where other important information, such as the caller’s name,

the conditions i.e. heavy or thick smoke, the location of the caller within the premises, their

proximity to the fire and the latest FSG advice given by Control to the caller, was communicated

to the incident.

345 The Lakanal House Incident Assurance Review commissioned by GTIRT to support its

investigation noted in its report, dated 7th August 2018, that training records show that fire

survival guidance refresher training has not been completed by all Control staff on an annual basis

in accordance with national guidance (Fire Service Circular 10/1993 ‘Training of Fire Control Staff’

and Brigade expectations as set out in its pre-Inquest actions (identified as Action 12 of the Pre-

Inquest actions within the report) following the Lakanal House fire.

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346 As part of the refresher training referred to above, the Brigade identified an action (Action 8 of

Pre-Inquest Actions) following the Lakanal House fire to include an input from Fire Safety Officers

in Control FSG training to comply with the requirements of Fire Service Circular 10/93. The

Lakanal House Incident Assurance Review report notes that ‘Whilst Fire Safety Officers were

involved in developing the building structure / fire safety issues content for the fire survival

guidance training and they have delivered the content on initial training, they have not

consistently delivered that content in refresher training’.

347 It is appropriate to acknowledge the extraordinary challenge that handling FSG calls presents in

normal circumstances, let alone in the extreme situation presented by the Grenfell Tower fire, in

that they are required to provide appropriate advice to persons, who are often in danger and

acute distress. This has to be undertaken from a remote position and with limited situational

awareness. The circumstances of the Grenfell Tower fire increased those challenges

exponentially.

348 It should also be noted that PN 539 anticipates that a CRO handling a FSG call will be supported

and assisted by supervisors and other CROs. The circumstances of the Grenfell Tower fire meant

that such support was not available due to the volume of calls being received.

Actions by the Brigade since the fire

349 All Brigade Control staff have undertaken FSG refresher training during 2018 and further

training will be undertaken this year once the revisions to PN 790 are published. At the time of

writing, five of the six Brigade Control Watches have taken part in the exercises that are informing

the revision of PN 790 and the associated procedures with the sixth Watch due to participate in

the final exercise shortly.

350 A competency framework for all levels of Brigade Control staff identifying core skills and

frequency of training to support maintenance of competence is currently being developed.

351 A new IT solution was implemented towards the end of 2018 to support the planning, delivery

and recording of Brigade Control training. The new solution ensures that training activities are

automatically recorded within Individual Training Records.

352 A facilitated discussion with Control staff around the challenges presented by the Grenfell

Tower fire has been led by Control senior managers, supported by the Operational Support Team

(OST) to ensure that all staff are aware of the ad hoc actions taken on the night where these were

considered effective. Where actions taken on the night were identified as not being effective,

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staff are discussing the situation which precipitated the original action and seeking to agree

possible improvements. It is recognised this training is an interim measure prior to the

implementation of revised policies, technological and training solutions that will be associated

with the updated PN 790.

Key observation 5.3 : There was no established or tested method to maintain an overview

of the FSG call information being received by Brigade.

353 Brigade Control received a total of 408 ‘999’ calls from 0054hrs up to 0800hrs related to

Grenfell Tower, and also handled 212 similarly related admin calls in this period. This volume is

completely unprecedented in the collective memory of the Brigade and does not include calls

related to other incidents ongoing in London during this period. On duty staff were also dealing

with the large volume of appliance mobilisations and notification protocols associated with the

fire, whilst attempting to manage the incoming calls and the transfer of risk critical information to

the incident.

354 The first of 152 calls from persons located within Grenfell Tower was received by Brigade

Control at 01:21hrs and the volume increased exponentially to an extent that British Telecom

began transferring calls to other fire and rescue service Control rooms, namely North West Fire

Control, Essex FRS, Surrey FRS, and Kent FRS. There is also evidence that calls were received by

other agencies during the course of the night such as the MPS and LAS.

355 Such was the intensity of the calls being received by Brigade Control, a queue quickly built up

within the system, impacting on the ability to maintain an adequate degree of situational

awareness in regard to the rapidly developing situation at Grenfell Tower. This situation was

alleviated to an extent by the arrival of the Brigade Control Duty Senior Manager who arrived at

Stratford at approx. 02:15hrs.

356 A white board system was then implemented to display FSG call information to provide shared

situational awareness in the room and enable CROs to correlate information, should any further

calls come in from the same flats or floors. The white board system was not a recognised or tested

procedure but an ad hoc measure established to ensure information was immediately available

and could be utilised by CROs handling calls and providing advice to callers. The information was

also available to the Brigade Coordination Centre (BCC) which had been set up at Stratford in

response to the major incident.

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Actions by the Brigade since the fire

357 A large wall screen has been fitted at the primary Control facility at Merton to increase shared

situational awareness amongst Control staff. The screen is able to display the DCT, the heli-tele

downlink feed, and information sourced from the Vision mobilising system including incidents in

progress. In addition, the screen is able to display television broadcasts. As yet there are no plans

to provide a similar system at the fall back location in Stratford although it is noted that all such

information is available at individual CRO work stations.

Recommendation 11 - It is suggested the Brigade considers how shared situational awareness

within the Control room might be achieved in similar circumstances and whether a more

sophisticated system than the whiteboards used on the 14th June should be developed and

implemented as an established Control protocol.

Key observation 5.4 : The ‘Vision’ mobilising system does not support the identification of

telephone numbers to enable call backs, and the Brigade does not have a clear policy

position on re-contacting callers.

358 PN 539 and the associated RIF requires that CROs maintain contact with callers being provided

with fire survival guidance until they are rescued or are able to self evacuate. As detailed earlier in

this report, the volume of calls and the rapidity with which they were received resulted in CROs

not keeping calls open with those located in the building, in order to reduce the queue that had

built up in the system.

359 The Brigade does not have a policy regarding re-contacting callers as the requirement to re-

contact was not envisaged. Callers on 14th June were provided with guidance and advised to call

‘999’ again if the situation changed or deteriorated and the CRO ended the call in order to answer

the next call. CROs had no means to know, before answering, if calls queuing in the system were

from residents at risk in the building or from those reporting the fire from outside and not in

danger.

360 Evidence demonstrates that callers did re-contact Brigade Control on many occasions during

the course of the night and some residents made a number of ‘999’ calls as conditions

deteriorated and their situation got worse. It is unlikely that residents making repeat calls would

have spoken with the same CRO.

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361 For those residents who called ‘999’ after the decision to advise all persons to leave the

building whatever the dangers they faced, CROs were able to provide instructions to evacuate

the building using wet towels to protect themselves.

362 For residents who did not or could not call after this time, this presented a serious situation, in

that the Brigade had no means to advise them to leave their flat unless an individual made a

further emergency call.

363 When questioned by Counsel to the Inquiry on this subject, one Brigade witness explained that

such a situation was beyond the experience of the Brigade and described how it would have been

very difficult to recontact callers as Brigade Control was inundated with emergency calls at that

time, with many calls held in a queue. The witness went on to describe how it would have been

very time consuming to search through call records to find the correct telephone number to

recontact the caller.

364 When asked how previous FSG callers would know that the advice had changed, the witness

reiterated that it was very difficult situation and such were the circumstances on the night that

there was a reliance on those trapped calling ‘999’ again, in which case they would be provided

with the appropriate advice.

365 In addition to the resourcing issues associated with attempting to recontact callers, it is noted

that the Vision mobilising system does not have a facility that makes the identification of previous

callers and their phone numbers easy or timely. This is, perhaps, not unsurprising as it was not

anticipated that such a situation would occur and such a facility would be required. As a result,

this was not included in the technical specification for the current mobilising system.

Actions by the Brigade since the fire

366 The Brigade’s OPA department have been asked to consider this issue in the review of PN 790

and FSG procedures. However, it is noted that any changes to the current mobilising system in

this respect are probably not achievable and would have to be included in the specification for

any future replacement mobilising system.

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Key observation 5.5 : There are no national standards for passing and receiving FSG call

information between Fire and Rescue Service Control rooms handling calls related to the

same incident.

367 The Brigade, like all emergency services have established mutual aid arrangements in place

with other Control rooms to answer and handle ‘999’ calls including FSG calls should its own

capacity be exceeded as a result of a major incident or spate conditions such as widespread

flooding.

368 On the 14th June 2017, five fire and rescue service Controls, North West, Essex, Surrey,

Merseyside and Kent provided mutual aid support to the Brigade by handling overflow calls,

many of which were Grenfell Tower FSG calls. All fire and rescue services use the Escape, Assess,

Protect and Rescue protocol for handling FSG calls so callers directed to these supporting

Controls received fire survival guidance based on the same principles used by Brigade Control.

369 However, it is noted that the sharing of information in a timely and effective manner between

the supporting Controls and Brigade Control was problematic. The sharing of FSG information

being received by the supporting Controls was affected by the volume of calls being received in

Brigade Control resulting in limited capacity to answer calls from the supporting Controls.

Similarly Brigade Control found it challenging, in resource terms, to pass information to the

supporting Controls to ensure shared situational awareness.

370 It is observed that there are no national standards for passing and receiving information

between Control rooms handling FSG calls arising from the same incident to support the existing

mutual aid arrangements.

371 It is further noted that much of the specific guidance available to fire and rescue services is

historic. Fire Service Circular 10/1993 ‘Training of Fire Control Staff’ is a relevant example of this.

NOG provides information on control and mobilising functions across its suite of guidance,

however there is no specific ‘one stop’ guidance provided for fire and rescue services addressing

the delivery of the relevant statutory duties required under the Fire and Rescue Service Act 2004.

Actions by the Brigade since the fire

372 Brigade Control senior managers are engaging with the NFCC Mobilising Officers Group

(MOG) to discuss how to improve the communication of information between Controls involved

in taking overflow calls under the established mutual aid arrangements.

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373 The group is carefully considering the Grenfell Tower fire and the challenges presented by a

number of Controls simultaneously handling calls relating to the same incident. The group

considers the establishment of a dedicated national Airwave talk group for Fire Controls could

enable the affected Control to simultaneously broadcast information to all Controls handling

overflow calls and ensure supporting Controls can communicate information to the affected

Control.

374 This proposal, if confirmed by the NFCC MOG, will need to be presented to the NFCC

Operations Committee for approval.

375 The NOL Secretariat has also been contacted regarding this issue and is examining the issue to

identify improvements which could be made to national guidance.

Key observation 5.6 : There is no automated system to link NICE voice records to Vision

call records, impacting on any post incident review.

376 The Brigade’s call management system is made of four key components, one of which is the

NICE11 voice recording system. The recording system for all incoming ‘999’ calls and the

administration lines is stand alone and does not create a unique reference that aligns to the Vision

mobilising system call records or the BOSS desk top incident viewer12.

377 When a 999 call is connected to the call handling system by the BT operator, the system

immediately starts to record and includes the period whilst the call is waiting to be answered by

Brigade Control. Once answered, the recording continues until the CRO ends the call, the caller

hangs up or the call drops out because of a loss of signal or a malfunction.

378 The system captures all voice interaction on the line which includes the BT operator passing the

call to the CRO. If the caller drops off the line or the call is cut off before being answered the

recording will continue, this allows for the capture of any conversation with the BT Operator.

379 This system is not linked to other components in the system and as a result, when collating call

data for review the voice records have to be manually cross referenced against the incident

records on the BOSS desk top viewer application.

11 NICE is the name of the company that make the software package installed on a stand alone computer.

12 BOSS is a software application used to present incident information to Brigade personnel without the need to access

the Vision mobilising system.

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380 It was identified that times presented in the BOSS desktop viewer do not align with the call

times associated with the audio recording because the BOSS application includes the ring time

before the call is answered. The BOSS application also uses the ‘created time’ as the call time

which is subject to variation depending on the call handling time and the selection of the ‘create

record’ action.

381 During the exercise to gather information for the Actions by Brigade Control report, appended

as Appendix B, voice recordings were found to be referenced against the wrong incident record

i.e. the phone number did not correspond to the NICE record, effectively meaning that call

information was held against the record of another call. There were also examples of voice call

records not allocated to a incident record at all resulting in new records being created several

months after the event.

382 Whilst these issues did not impact on the night, the reconciliation of call data presented a

significant challenge for GTIRT who worked collaboratively with the Inquiry and MPS to ensure

an accurate record of all calls related to the Grenfell Tower fire was adduced into evidence.

Actions by the Brigade since the fire

383 It is acknowledged that overcoming these issues requires a significant change to the Brigade’s

communications and mobilising systems and it not feasible until the future replacement of those

systems.

384 These issues will also be captured as learning in a future guidance document to be produced as

an appendix to PN 920 ‘Major incidents investigation’ to ensure future investigations are sighted

on the issues identified during the Grenfell Tower safety and learning investigation. A new

working group will convene in April 2019 to scope out work required to produce effective

guidance to support future investigations.

Key observation 5.7 : The ‘Vision’ mobilising system ‘call collection form’ can be

overwritten if a new call is taken before it is added to the incident log.

385 During the collation of call data it became apparent that audio records of 999 calls had been

captured on the NICE recording system that were not recorded against an incident record.

386 When a CRO answers a ‘999’ call on the Integrated Control and Communications System

(ICCS), a ‘call collection form’ automatically opens on the Vision mobilising system. Some details

of the call are automatically populated and the CRO is required to gather and enter other data

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manually by asking the caller questions. When the CRO has reached the point that they are

satisfied they have gathered all relevant information, an incident record is created and, where

appropriate, the required resources are mobilised.

387 When large numbers of calls are received to the same incident the mobilising system provides

the facility to ‘duplicate’ calls when a CRO determines the incident being reported is the same as

an incident already being attended by the Brigade. In this event, a copy of the incident record is

created and becomes a duplicate. The duplicate has a separate incident number but is linked to

the original record created for the incident. This process assists the Brigade in managing call

volumes and avoids unnecessary mobilisation of resources.

388 During the Brigade’s investigation a review of the NICE recording system was undertaken to

ensure all audio records had been captured. It was identified that several ‘999’ call records were

captured which were not assigned to an incident record. It was also observed that is some cases

two phone numbers were captured in the same incident record. On further investigation it was

apparent that it is possible to answer a ‘999’ call through the ICCS system with the previous call

collection form still open, resulting in the new call number becoming embedded in the previous

incident record.

389 Following any incident the collation of call data forms an important part of the evidence

required to provide assurance to the organisation. The issue identified as key observation 5.6

results in investigators having to listen to the audio file for each call and manually cross reference

these to incident logs to ensure all evidence is captured and is accurate.

390 While the issues identified above did not impact on the night of the fire, it did result in

considerable delay in identifying all incident records to support the post incident investigation

and review activities related to the Grenfell Tower fire.

Actions by the Brigade since the fire

391 This issue has been communicated to Brigade Control senior managers and has been

addressed during the facilitated discussions (paragraph 352 refers) to ensure Control staff are

fully aware of the issue and take active measures to prevent a re-occurrence during future

incidents involving large numbers of incoming calls.

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Key observation 5.8 : There is potential for Brigade Control personnel to experience

secondary trauma following a traumatic incident.

392 Following the Grenfell Tower fire there were a significant number of counselling referrals from

Brigade Control staff and high levels of sickness absence were recorded, mostly related to stress,

anxiety and depression (SAD).

393 Sickness arising from participating in the Grenfell Tower fire response and the public inquiry

continues to contribute to sickness absence. The increasing number of episodes of sickness

absence due to SAD, combined with the fact that episodes of SAD absence usually last longer

than other causes of sickness absence, continues to drive up headline absence rates. The

Brigade’s target for sickness absence for Brigade Control staff is 4.7% of working days lost, but

has remained consistently above this figure since the Grenfell Tower fire and peaked at 9.06%.

394 On the night of the fire the Counselling and Welfare Services (CWS) duty counsellor was

contacted by Brigade Control at approximately 03:00hrs on the day of the fire. A request was

made to provide a counsellor to go to Brigade Control at Stratford to support CROs and

managers. The Head of CWS was notified of this request and decided to go to Stratford as she

was the nearest counsellor and arrived at Brigade Control approximately two hours after the initial

call.

395 In Brigade Control, the Head of CWS met with managers and all the No. 2 Watch CROs

involved in dealing with the calls from residents and other people close to the Grenfell Tower. At

the end of their shift the CROs were provided with psychological first aid and support prior to

them leaving to go home.

396 It is noted that one month after the fire, 19% of Brigade Control staff involved in the incident

had been referred to CWS, this compares with 20% of firefighters involved in rescue operations.

Actions by the Brigade since the fire

397 The Head of GTIRT recently commissioned an independent study of the Brigade’s counselling

and trauma service provision during and following the Grenfell Tower fire by Dr Noreen Tehrani,

Past Chair of the Crisis, Disaster and Trauma Section of the British Psychological Society and a

member of the Crisis, Disaster and Trauma Standing Committee for the European Federation of

Psychological Associations.

398 Dr Tehrani made the following recommendations in her report in March 2019:

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Firefighters and others in high risk roles such as Brigade Control staff should be submitted to

regular psychological surveillance, to manage the risk of psychological health in the same way

that physical health is managed.

Following a major incident, the use of ‘screen and treat’ for all involved personnel would help

to identify those likely to develop trauma related conditions.

399 Dr Tehrani also suggested the following changes be considered by the Brigade:

Introduction of trained peer trauma support volunteers

Increased mandatory/routine psychological screening of those involved

Additional psychosocial support for Brigade Control personnel

Increased support for senior officers

400 The report will be considered by the Brigade in April 2019 to determine its response to Dr

Tehrani’s recommendations.

Theme 6 – Communications

Key observation 6.1: The volume of hand held radio traffic exceeded the capacity of both

the breathing apparatus and command channel.

401 A number of witnesses stated in oral evidence that they had difficulty in communicating on the

fire ground using their hand held radios and in the building using BARIE13 sets. Other witnesses

said that the hand held radios were not working. The Brigade employs two main forms of

communication equipment. A digital national radio system, ‘Airwave’ for wide area

communications (Brigade Control to appliances) and a system of personal issue analogue

‘fireground’ radios for local use at incidents.

402 The Brigade’s hand held radios (Entel HX-480/1) are issued to all operational staff and are

programmed with 10 separate channels. These are detailed below:

Channels 1 and 2 - General Incident and Command channels

Channel 3 - Used under direction of the IC / sector commander for firefighter

communications during specific tasks

Channel 4 - To be used only under direction of the duty radio officer

13 Breathing Apparatus Radio Interface Equipment

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Channel 5 - For communications (including BA) where a leaky feeder or base station

equipment is installed

Channel 6 - BA

Channel 7 - To be used only under the direction of the duty radio officer

Channel 8 - For communications in specific buildings where leaky feeder or appropriate base

station equipment is installed

Channel 10 - For use by the CU staff

403 An intrinsically safe variant, the Entel HT981 is used within the BARIE system (PN 592 refers).

Intrinsic safety is achieved by capping output at one watt.

404 It should be noted that channels 2, 5 and 8 are duplex14 and will only work in conjunction with a

repeater set available when a CU is in attendance or a base station is fitted in the premises, e.g.

London Underground stations.

405 Channel 1 is reserved for all initial incident command communications. It remains the primary

command channel until the circumstances of the incident dictate or the IC decides that additional

command and control radio capacity is required.

406 Once a CU is in attendance the CU communications operator will advise the IC that channel 2 is

available to be introduced as the command channel if required.

407 Channel 6 is the default channel for BA communications unless the premises involved has a

base station and leaky feeder installed, such as London Underground stations. In this case

Channel 5 will be used for BA Communications. During the Grenfell Tower fire only Channel 1

was utilised for command communications and Channel 6 was primarily used for BA

communications.

408 In the aftermath of the fire the Brigade undertook a number of controlled radio signal

propagation tests in and around Grenfell Tower testing both the hand held radios, BARIE system,

and telemetry equipment. Tests on all floors and throughout the inner stair case on Channels 6

and 2 utilised a standard HX480 radio at the BA control board locations and BARIE variant at

remote locations within the building.

14 Duplex channel radio systems describe the use of two frequency channels, usually in the same band spectrum, which

allows simultaneous communication between two stations.

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409 It is noted that when these tests were undertaken the fabric of the building was substantially

altered from the night of the fire. The results of the tests are detailed below:

TEST 1. - Channel 1 within inner cordon. Channel 1 transmissions and reception were clear

during all tests. Within all areas of the inner cordon and the atrium of Grenfell Tower radio

messages were clearly audible without signal loss.

TEST 2. Channel 1 at original CU location. Channel 1 transmission and reception clear during

all test calls. Within all areas of the inner cordon and the atrium of Grenfell Tower it was possible

to transmit to and receive messages from a radio placed at the original CU location.

With the Channel 2 repeater deployed at the original CU location Tests 1 and 2 were repeated.

Channel 2 transmissions and reception were clear during all tests. From the original CU location

to all areas of the inner cordon and atrium test messages were clearly audible without signal loss.

TEST 3. Channel 1 at Bridge Head locations to and from all floors. Channel 1

transmissions on all floors from all bridgehead locations (floors 0,2,3 and 7) clearly audible

without signal loss with the following exceptions:

Floor 7 (bridgehead at floor 0) - Slight background noise within lift lobby, but message still

audible and understood.

Floor 10 (Bridgehead at floor 0) - missed number during test count, repeated clearly received.

Floor 23 (bridgehead at floor 0) - slight clipping of received signal, message audible when

repeated.

Roof level (bridgehead at floor 0) - transmission from West side of roof area broken and

inaudible when receiving at floor 0 (atrium).

Channel 6 BA radio test. Bridge Head BA entry control locations to and from BA wearers on all

floors.

Channel 6 BA transmissions on all floors from all bridge head locations (floors 0,2,4,7) clearly

audible without signal loss with the following exceptions.

Floor 13 (bridgehead at floor 0) - 1-2 second loss on transmission from BA wearer within

lobby area.

Floor 16 (bridgehead at floor 0) - slight signal loss within flat 1 regained clear transmission

from lobby.

Roof level - Not tested by BA wearers.

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Channel 2 (repeater at original CU location) to and from all floors.

Channel 2 transmission and reception was intermittent when leaving the atrium and

proceeding within the central stairwell of the building up until reaching floor 3. From floor 3

communication was possible from within flats but broken within the central stair core of the

building.

From floor 7 communication on channel 2 improved but was still breaking at times.

On floor 17 difficulties were experienced with interference. It was found that when

transmitting on Channel 6 a whine was experienced on equipment monitoring channel 2

rendering reception of the test message inaudible.

410 Recognising the potential for signals to be reflected from surrounding buildings back into

Grenfell Tower a further test was carried out within the central core of the building on upper

floors to assist in ruling out the scenario. A radio operator on channel 1 was placed at floor 11

(above the level of any surrounding buildings) and test calls were then made to a radio operator

ascending the building floors 12 to roof. Test messages were clearly received on all floors from 12

to roof level.

411 The Grenfell Tower fire was one of the largest and most complex incident communication

challenges the Brigade has ever experienced. At the height of the response phase of the fire

there was in excess of over 300 hand held radios available and potentially in use at the incident.

412 Given this fact and taking into consideration the radio propagation test results the most likely

cause of the radio communication issues is the sheer volume of radio traffic being generated. This

situation would have also been exacerbated by the unprecedented volume of BA crews deployed

to undertake search, rescue and firefighting operations during this incident.

Actions by the Brigade since the fire

413 The Brigade is reviewing its handheld radio capability and is in the process of tendering for a

replacement radio handset. The Brigade officers involved in the radio replacement project have

been made aware of the issues experienced at the Grenfell Tower fire and will, if the technology

exists, select a replacement hand held radio that may mitigate some of these capacity challenges.

It is anticipated that the replacement of the BARIE and the standard handheld radios will be

completed in the 2019/20 financial period.

414 In addition to replacing the hand held radios the Brigade’s OPA department are reviewing the

current guidance that is available to staff in respect to radio protocol. It is acknowledged that at

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large scale and complex incidents where a significant number of hand held radios could be

potentially used that operational staff may need to exercise more radio discipline in terms of

generating radio traffic so as not too overrun the capacity of the available radio channels.

Key observation 6.2: There is evidence of a lack of knowledge and understanding of the

potential tactics and associated equipment that may have mitigated radio communication

issues.

415 Evidence from Brigade staff points to a lack of knowledge and understanding of the equipment

available to potentially mitigate the radio communication issues experienced during the incident.

As can be seen in the findings detailed above, the requirement to deploy the Brigade’s radio

repeater and leaky feeder capability probably wasn’t required at this incident as the radio

communication issues experienced at the Grenfell Tower fire were primarily caused by the sheer

volume of radio traffic being generated.

Actions by the Brigade since the fire

416 To address the knowledge and understanding issue, two mandatory communications training

packages, one of which specifically covers the capability and deployment of the Brigade’s radio

repeater and leaky feeder equipment have been made available to all operational staff as part of

the Operational News publication (Ops News 36, February 2019).

Key observation 6.3: Senior officers were unable to book in attendance at the incident

due to the high volume of radio traffic on the Airwave main scheme radio.

417 In reviewing the available data from the ‘Vision’ mobilising log it has been identified that a

number of officers (and appliances) did not book in attendance with Brigade Control when they

arrived at the incident as required by PN 23815 and PN 16216. Booking in attendance with Brigade

Control is required to confirm that the asset has arrived safely at the incident they were mobilised

to.

418 Booking in attendance provides a date and time stamp, which is used to measure attendance

times for pumping appliances, which is one of the Brigade’s key performance indicators. This date

and time stamp data can also be used for post incident review and investigation and greatly assists

in producing a detailed timeline of incident, if required.

15 Incident command procedures

16 Officer responsibilities at incidents

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419 In producing the STEP timeline of activities the GTIRT has overcome this issue by cross

referencing other data sources and the available Global Positioning System (GPS) information,

mobile phone footage and CCTV imagery. This has enabled GTIRT to place officers and other

resources at the incident with a reasonable degree of accuracy.

Actions by the Brigade since the fire

420 In an attempt to overcome this issue the Brigade has reviewed the capability of the ‘Airwave’

hand held radios to establish if the equipment will allow an officer to book in attendance with

Brigade Control without recourse to sending an oral message, i.e. will the equipment and the

mobilising system allow for a data message to be sent and acknowledged.

421 This review confirmed that while the ‘Airwave’ hand held radios have this functionality the

Brigade’s mobilising system is not currently set up to process text data received from the

‘Airwave’ handset. Capita, the company that supplied and maintains the Brigade’s mobilising

system, is currently scoping the work and associated costs involved in adding this capability to the

Brigade’s mobilising system.

Key observation 6.4: There was a lack of information provided to Brigade Control on

progress with search and rescue operations.

422 As previously covered in this report (Theme 5 refers) the sheer scale and unprecedented

number of calls, both emergency and FSG, overwhelmed the capacity of the CROs who,

understandably, were trying to answer as many of the ‘999’ calls as possible.

423 At the incident the same problem occurred as the command structure, the Fire Sector and FSG

CU in particular, became overwhelmed with the volume of information that they had to process

and disseminate. This led to a lack of situational awareness in Brigade Control who were advising

residents and providing fire survival guidance to callers over a protracted period.

424 PN 790 states that once a FSG Coordinator is appointed at the incident this officer should make

contact with a supervisor in Brigade Control. This contact is to keep Brigade Control appraised of

developments and progress relating to the search and rescue of those residents involved in FSG

calls.

425 The evidence shows that the sheer volume of information coming into the FSG CU left them

little, if any, opportunity to contact a supervisor in Brigade Control. It is also clear that all the

supervisory managers in Brigade Control were fully engaged in call handling and mobilising

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activities for an extended period of time so no-one would have been available to communicate

with the FSG Coordinator, even had this officer attempted to make contact with Brigade Control.

Actions by the Brigade since the fire

426 As a result of these findings the Brigade has initiated a comprehensive review of its FSG policy

and procedures which has included undertaking a range of exercises to establish at what point, in

terms of the number of FSG calls, does Brigade Control and the FSG CU functions, as detailed in

current policy become overwhelmed. The findings from these exercises will be incorporated into

updated FSG procedures.

Key observation 6.5: Dissemination of FSG call information between the CU and the

Bridgehead was delivered via multiple communication channels as the volume and sources

of information increased.

427 There is evidence that multiple information exchange processes were established at the

incident for the dissemination of FSG call information between the FSG CU and the Bridgehead.

Some information was passed by hand held radio communications while at other times ‘runners’

were used. These communication channels were implemented incrementally as the volume of

FSG calls and information increased.

428 It is also evident that as the incident developed, and the various FSG call communications

channels were implemented, there was minimal shared situational awareness of the process for

disseminating and exchanging this information.

429 There is also evidence that the officers deployed on the FSG CU did not consistently use the

‘Control Information’ forms, which are available on all front line fire engines. These forms are

carbonated so that the casualty information can be shared at the incident with one copy being

retained by the CU staff for post incident analysis. There is evidence that other forms of paper

records were used to pass some FSG call information and at times this was passed via a number of

officers before it reached the Bridgehead.

Actions by the Brigade since the fire

430 Improvements to this area form part of the review work currently being undertaken to update

the Brigade’s FSG policy, which will be published later this year.

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Key observations 6.6: There was limited practical means to communicate with all the

residents in the building to provide advice and/or instruct an evacuation.

431 During Phase 1 of the Inquiry there has been a considerable focus on why the Brigade did not

initiate a full evacuation of the Grenfell Tower during the early stages of the incident when it was

first recognised that the fire was spreading rapidly beyond the flat of origin. While this is an

understandable line of enquiry the Brigade has repeatedly, both in oral evidence and in its

‘Opening’ and ‘Closing’ statements, explained that the full evacuation of a residential high rise

premises, with the building design of Grenfell Tower, is a complex challenge.

432 As stated earlier in this report, Grenfell Tower was not fitted with a building wide

communications system that could have been utilised by the Brigade to alert residents to

evacuate the building.

433 Without any integral communications systems, the Brigade is left with very limited options to

initiate an effective and efficient full evacuation of this type of premises during a major fire. In a

single staircase residential high rise building, such as Grenfell Tower, this problem is further

exacerbated as a full evacuation would greatly impact on the fire and rescue service undertaking

its firefighting, search and rescue operations. This could place residents at additional risk

especially when the fire is spreading rapidly and the Brigade is hampered in its firefighting

operation.

434 The Brigade does have some limited capability, such as loudhailers, that can be used to

communicate with residents from a distance. However, while there is evidence that loudhailers

were employed to a limited extent by Brigade at the Grenfell Tower fire it is unlikely to be an

effective way of communicating with residents located on the upper floors of a residential high

rise building.

435 As such, the only way that the Brigade can fully evacuate a building is to commit large numbers

of firefighters in BA into the building to knock and potentially force entry to every flat. This is both

very arduous, due to the poor conditions in the staircase and lobbies, and inefficient in terms of

being able to evacuate the whole block quickly. Such a decision would require the IC to operate

outside of agreed operational policy as it would require firefighters to go above the known fire

floors without any firefighting media, placing firefighters in significant danger.

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Actions by the Brigade since the fire

436 The Brigade recognises the importance of evacuation procedures and the means to implement

such procedures is to the bereaved, survivors and residents but it also believes it is not something

the Brigade can resolve on its own. Grenfell Tower was not originally designed to support a full

evacuation of residents and as such the building did not contain the means with which to alert

residents or coordinate a full evacuation.

437 The Brigade will continue to work with all stakeholders to identify and deliver improvements to

the regulatory regime to prevent a re-occurrence of the Grenfell Tower fire and increase the

safety of the public and firefighters.

438 The Brigade’s OPA department also continues to review PN 633 and work with other fire and

rescue services to identify solutions to mitigate the issues described above, until changes to the

regulatory regime, such as those recommended by the Hackitt Review, are implemented.

However the challenge of identifying workable and safe procedures to overcome the

fundamental design principles of buildings described above is significant and practically difficult.

439 For those buildings identified as being fitted with ACM cladding similar to that installed at

Grenfell Tower and until the cladding is removed, the NFCC simultaneous evacuation guidance

should be applied by the responsible person and requires, either, the installation of a central

alarm system or the provision of a waking watch to alert residents to a fire and initiate an

evacuation.

Key observation 6.7: There was no declaration of a ‘Firefighter Emergency’ to Brigade

Control in accordance with Policy Note 496.

440 From reviewing the Brigade’s witness statements it has been identified that there were three

Firefighter Emergency (FFE) events during the incident that were not formally declared in a

message to Brigade Control, as required by PN 49617. In policy the term FFE applies whenever

operational staff, or persons working under the control of the Brigade, are unaccounted for

and/or in need of rescue.

441 If it is established or there is strong evidence to suggest that one or more firefighters or

personnel working under the control of the Brigade are unaccounted for and/or in need of rescue

the IC will immediately send the following priority message:

17 Tactical withdrawal, emergency evacuation and firefighter emergency

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“From (Name of IC) at (address of incident), Firefighter Emergency, Tactical Mode Oscar”.

442 The FFE message will prompt Brigade Control to mobilise the following resources:

Six Pumping appliances

Two Fire Rescue Units

Fire Investigation Unit

Command Unit

An ambulance

Press Liaison Officer

Senior Fire Safety Officer

Three Station Manager

Group Manager

Deputy Assistant Commissioner

Senior Accident Investigator (SAI).

443 PN 496 directs that this attendance will be mobilised in full, regardless of the resources in

attendance or en route. If the size of the incident is subsequently increased, the mobilising system

will not include the resources ordered for 'FFE' when calculating the additional attendance

required.

444 Through further investigation of this issue it has been confirmed that while the FFE messages

were not sent to Brigade Control, the Brigade did respond appropriately to these safety events by

diverting resources to deal with the situation as a priority.

445 It has also been established that a conscious decision was made not to initiate the FFE message

as they were aware that Brigade Control were already dealing with an unprecedented number of

999 and FSG calls and the further mobilisations required by the policy would create additional

pressure and work for Brigade Control.

446 Evidence provided by witnesses also suggest the situation was assessed and it was determined

the Brigade had sufficient resources in attendance at the time the events occurred to respond

effectively to each FFE and the automatic mobilisation of the FFE PDA would further deplete the

Brigade available operational resources.

Recommendation 12 - The Brigade should consider whether any improvement measures are

necessary in relation to policy and training, noting the context provided in the preceding paragraphs.

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Key Observation 6.8: From 02:06hrs FSG call information was passed from Brigade

Control to the incident by a mobile phone to a mobile phone link resulting in a lack of

evidence to support the post incident review and investigation.

447 Evidence provided during Phase 1 of the Inquiry illustrates the transfer of FSG call information

from Brigade Control to the incident did not follow the guidance contained in policy. PN 790

states that if there are a large number of FSG calls in progress and Brigade Control has sufficient

resources then main scheme channel 118 can be used to avoid impacting on the main scheme

radio channel in use.

448 Brigade Control also has a ‘CU critical’ phone line which has a higher priority than calls to the

Officer of the Watch (OOW), which is the role normally undertaken by the on duty OM in

Brigade Control. This number is programmed into CU phones and is used for passing life critical

information securely. Both of these systems for passing FSG information are recorded.

449 During the Grenfell Tower fire mobile phones were used to pass FSG information from Brigade

Control to the incident. The evidence suggests that this was done as a result of the high volume

of FSG calls being taken and to keep the main scheme radio channel clear to send and receive

‘Assistance’ and ‘Informative’ messages relating to the Grenfell Tower fire and other incidents and

enable CROs to focus on answering emergency calls.

450 The main issue arising from this situation is that the Brigade has no voice recordings relating to

the FSG call information sent by this method. This has made tracking the FSG call information as

part of the safety and learning investigation more difficult.

Actions by the Brigade since the fire

451 This issue is currently being considered as part of the review of the Brigade’s FSG policy and

procedures being undertaken by the Brigade’s OPA department, who have been working closely

with GTIRT to fully understand the challenges and issues that arose during the Grenfell Tower fire

in respect to the handling and management of FSG calls. The lessons learnt from the incident will

be captured and reflected in the revised FSG policy guidance and the associated training

solution(s) that will be developed.

18 M2FH FLON-OPS-01

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Theme 7 – Operational Equipment

Key Observations 7.1: The Command Support System was unreliable during the incident.

452 On the night of the Grenfell Tower fire it was stated in evidence by several CU operatives that

the CSS did not work.

453 A Brigade witness when asked about the CSS on CU8 stated in oral evidence that on arrival at

the incident around 02:20hrs that the CSS failed to start up, despite repeated attempts. The

decision log maintained on CU8 after 02:47hrs notes at 04:03hrs that ‘Command Support System

has gone down’.

454 However, another Brigade witness when questioned about whether there were any problems

with the CSS on CU8 that night responded by stating that he could not remember any issues with

the system but further noted that he had little involvement with the CSS during the night. This is

supported by another witness who noted in his voluntary police statement that the CSS was

working when he arrived on CU8 just before 04:00hrs and even took a photo of the command

structure illustrated on the system.

455 Historically the problems with CSS at incidents are well documented and these issues were

referred to a number of times in oral and written evidence. In these circumstances, officers and

CU staff use alternative equipment provided on the CUs to manually record the same information

that would ordinarily be populated on the CSS. This alternative equipment includes blank

whiteboards and the ‘headline board’19 provided to record the incident command structure.

456 The CSS can provide a useful overview of the incident structure and as identified earlier in the

report be used to record key decisions.

457 It is noted that whilst there are acknowledged issues with the reliability of the CSS, the Brigade

has tried and tested methods to adapt and overcome these issues at operational incidents.

Actions by the Brigade since the fire

458 The Brigade is currently in the process of delivering the CU replacement vehicle project, which

aims to incorporate the latest technology to support its command, control and communications

functions to support operational incidents.

19 Board incorporating a template which can be annotated with information to illustrate the command structure being

employed at the incident.

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459 The commencement of this project pre-dates the Grenfell Tower fire and demonstrates that the

Brigade had already recognised the need to continually improve the functions delivered by CSS

and actively review the new equipment and software technologies now available.

460 In January 2019, and ahead of the delivery of the CU replacement project, scheduled for 2020,

the Brigade has rolled out two Windows 10, 4G enabled laptops to all seven CUs. This is to build

resilience in the systems and to ensure that even if the main computer on the CUs aren’t working

effectively or if a CU is unable to attend an incident the Brigade is still able to utilise the CSS

remotely. As part of the rollout of this new equipment the CSS software has been updated from

Version 1.0 to Version 1.7, which provides a more stable platform and is compatible with the

latest versions of the Windows 10 operating system.

461 The new software was tested for three months in the last quarter of the calendar year on

various CUs and training was provided for CU operatives. The CUs are currently being further

upgraded with new IT hardware which will allow the CSS to be used as originally intended on the

Units, i.e., on a large, dedicated display terminal. Once the upgrade is complete the laptops will

remain on the CUs to provide further resilience.

Key Observation 7.2: There was no mobilising protocol for the Brigade’s limited Positive

Pressure Ventilation capability.

462 The Brigade only had a limited PPV capability at the time of the Grenfell Tower fire. It was not

well known throughout the Brigade that this capability was under evaluation and available, as its

primary purpose is to assist the Brigade’s response to a Marauding Terrorist Firearms Attack

(MTFA) where fire may have been used as part of the deliberate attack.

463 Evidence shows that at 02:57hrs the Brigade’s IC requests, via the Duty DAC, the attendance

of Positive Pressure Ventilation (PPV). This request is made via a mobile phone call to Brigade

Control.

464 The Brigade has an established method of mobilising the majority of equipment/resources to

incidents, which is covered in PN 41220. However, as the PPV equipment currently only forms

part of a specialist response capability to a specific incident type it is not in general use. This is

why these vehicles and associated PPV equipment do not appear on the Pre Determined

Attendances (PDAs) on the ‘Vision’ mobilising system.

20 Mobilising policy

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465 This resulted in the PPV equipment, when requested, needed to be mobilised manually. This

was done by a SM who was located at the BCC, who instructed a WM, also at the BCC, to collect

the specialist vehicle carrying the two sets of PPV from the Brigade’s headquarters. The PPV

capability arrived on scene just after 04:00hrs and is seen at 05:03:20hrs being brought into the

Grenfell Tower ground floor lobby.

Actions by the Brigade since the fire

466 The Brigade has introduced a new mobilising protocol for the existing Special Operations PPV

equipment, which is now identified as an ‘attribute’ on the ‘Vision’ mobilising system. In March

2018 a new RIF was produced to support PPV mobilisations. These system changes enable PPV

to be mobilised either by the Duty National Interagency Liaison Officer (NILO) or in response to a

request from an incident. When PPV is requested from a routine fire incident the mobilisation

must be sanctioned by the Duty NILO and the Duty AC.

Recommendation 13 - It is suggested that the Brigade considers whether it needs to make

operational staff more aware of the currently available PPV capability and its uses.

Key Observation 7.3: A number of Breathing Apparatus sets were used more than once by

different wearers and there was no means to record the test or subsequent wearer.

467 Traditionally when firefighters report for duty they are required to do a test of their BA sets.

This is normally done at the beginning of the shift. Once the test is complete, whether the BA set

has passed or failed the firefighter will, as soon as practicably possible, fill out the corresponding

BA log book.

468 These BA log books are kept at the home station, enabling supervisory officers to check and

confirm all BA sets have been allocated and tested. To support the Brigade’s investigation and the

identification of BA teams, all log books were scanned to record their contents. This exercise

identified that some log books were not completed correctly and a small number had not

completed at all.

469 The log books remain on the station all the time the BA set is allocated to that station. The only

time the BA log book should be removed is when the equipment is sent to PEG for periodic

testing or when the equipment is defective. The log books are not carried on appliances with their

respective BA sets.

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470 At the Grenfell Tower fire between 01:04hrs and 08:11hrs there were 217 BA sets used by

firefighters. Between 08:11hrs and 20:00hrs, a further 169 BA sets were worn.

471 The Brigade still have 58 BA sets that are known to have been used during the fire after

08:00hrs which have not been attributed to an individual firefighter, i.e. the Brigade has been

able to confirm that the set was used during the fire, but is unable to identify by whom.

472 When firefighters exited Grenfell Tower some returned to their fire engine and performed a

fire ground ‘A’ Test. This is a basic test of the set to ensure it is safe to be used again. As the

incident escalated a specific area was established to service the sets and enable BA wearers to

rest and recover. There was no facility at this area to record the testing of sets as all BA log books

were at their respective fire stations.

473 The RPE Logistics Officers (RPELO) carry temporary log sheets that can be utilised on scene.

The duty RPELO arrived on scene at 04:45hrs and the temporary log sheets were utilised from

10:30hrs. Reserve Extended Duration BA sets were mobilised to the incident from PEG with the

accompanying log books but these were not used to record acceptance or fireground ‘A’ tests.

474 Whist there was no impact on the availability or usability of BA sets on the night of the Grenfell

Tower fire. The poor records in BA log books made it difficult to identify wearers, the sets those

wearers used and how those wearers were organised into teams when they entered the hazard

area.

Actions by the Brigade since the fire

475 The issues described above have been communicated to the RPE policy team and PEG for

consideration.

Key Observations 7.4: Time stamp on the Thermal Image Cameras were not aligned to

Greenwich Mean Time.

476 As part of the Brigade’s investigation and evidence gathering in the recovery phase of the

incident, the Brigade’s Fire Investigation (FI) officers undertook the task of identifying all of the

Thermal Image Cameras (TICs) used during the fire. The FI officers reviewed the footage

captured by the TICs as part of their own investigation as to the likely cause of the fire and

downloaded approximately 60 hours of footage from 22 cameras. This footage was uploaded

onto the Brigade’s Grenfell Tower image library.

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477 The footage was reviewed by GTIRT to identify which TIC belonged to which station, who

recorded the images and at what time, to corroborate the actions of firefighters, fire spread,

smoke movement and identification of residents inside Grenfell Tower.

478 It was observed that there were a number of inconsistencies with time stamps on the images

reviewed. Further investigation revealed that the TIC’s do not have an auto update feature which

automatically updates the time on the equipment to align with Greenwich Mean Time (GMT) and

British Summer Time (BST) as this requirement was not included in the procurement

specification.

479 The TICs do not provide a time indication whilst the equipment is being operated so any

inaccuracies are not apparent to the equipment user. As there is no automatic update facility on

this equipment the time has to be changed manually, which is normally only done once a year by

an external contractor during the equipment’s scheduled service. As a consequence it is highly

probable the time stored within the Brigade’s TICs will often be inaccurate.

480 All the TICs were subsequently examined by the Brigade and a retrospective calculation was

used to establish the time difference against the GMT. From this, GTIRT were able to establish an

approximate time for the majority of the TIC footage reviewed, which has been used to inform its

timeline and associated reports.

Actions by the Brigade since the fire

481 The issue described above was communicated to the TIC manufacturer and supplier in July

2017 by the Brigade’s Technical and Commercial department to enable a solution to overcome

the time stamp issue to be identified. The development of an approved solution is still being

progressed.

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Chapter 4 - Summary of key observations

Theme 1 - Observed failures of the building and its fire safety measures

Key observation 1.1 : The external cladding system installed on Grenfell Tower was not compliant

with Regulation B4(1), contributing to the observed failure of the fire safety measures provided

within the premises.

Theme 2 – Operational pre-planning

Key observation 2.1 : Any knowledge concerning the risks associated with cladding systems may not

been recognised and communicated effectively across the Brigade.

Key observation 2.2 : The Operational Risk Database entry for Grenfell Tower was not populated in

accordance with PN 800.

Key observation 2.3 : There is a lack of consistency in the standard of premises risk information held

on the Operational Risk Database.

Key observation 2.4: The Brigade has not undertaken Premises Risk Assessments for all residential

high rise premises to determine the level of risk associated with these premises.

Key observation 2.5 : There may be an inconsistent level of knowledge and understanding amongst

operational staff in relation to 7(2)d visits.

Key observation 2.6 : There is no established means for crews providing an emergency response to

premises outside of their own station areas to be aware of any fire safety deficiencies that may have

been identified.

Theme 3 – Command and Control

Key Observation 3.1 : The scale and rapidity of the incident, combined with human factors, impacted

on the ability to maintain situational awareness.

Key observation 3.2 : The rapid escalation of the incident impacted to a limited extent on command

handovers.

Key observation 3.3 : Effective early information gathering enabled the ‘on arrival’ tactics and actions

identified in PN 633 to be implemented effectively by the crews who formed the pre-determined

attendance for the incident.

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Key observation 3.4 : There was effective early recognition of resourcing requirements by ICs.

Key observation 3.5 : Recording of decisions, rationale, objectives and tactical plans was in some

regards ineffective.

Key observation 3.6 : Difficulty in confirming who was being rescued or self evacuating from the

building and from where created difficulty in maintaining accurate records to inform the search and

rescue operation.

Key observation 3.7 : Operational Discretion was adopted for the incident but it was not formally

recorded in accordance with Brigade policy.

Theme 4 – Operations

Key observation 4.1: The Brigade had limited means to fight an external façade fire resulting from

the non compliance of the installed external cladding system with the requirements of Regulation

B4(1).

Key observation 4. 2 : Extensive breaches of compartmentation resulted in simultaneous serious fires

on multiple floors.

Key observation 4.3 : The building behaved in an unpredictable manner beyond the experience of

the Brigade.

Key observation 4.4 : The building’s single escape route was significantly compromised by the

products of combustion from an early stage of the incident.

Key observation 4.5 : Number of FSG calls and the resulting volume of information significantly

exceeded the expectations of Brigade policy and training.

Key observation 4.6 : Operational personnel were required by circumstances to provide fire survival

guidance to residents, a task not anticipated by policy or training.

Key observation 4.7 : Operational crews had problems physically identifying floor numbers in the

stairwell.

Key observation 4.8 : Some elements of the BA operations during the Grenfell Tower fire were not

fully aligned to the Brigade’s operational procedures set out in PN 466.

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Theme 5 – Brigade Control

Key observation 5.1 : The facilities at the Brigade’s fallback Control, located in Stratford, did not fully

replicate those at the primary Control in Merton.

Key observation 5.2 : FSG call information was not gathered and communicated in accordance with

PN 539, Appendix 3.

Key observation 5.3 : There was no established or tested method to maintain an overview of the FSG

call information being received by Brigade.

Key observation 5.4 : The ‘Vision’ mobilising system does not support the identification of telephone

numbers to enable call backs, and the Brigade does not have a clear policy position on re-contacting

callers.

Key observation 5.5 : There are no national standards for passing and receiving FSG call information

between Fire and Rescue Service Control rooms handling calls related to the same incident.

Key observation 5.6 : There is no automated system to link NICE voice records to Vision call records,

impacting on any post incident review.

Key observation 5.7 : The ‘Vision’ mobilising system ‘call collection form’ can be overwritten if a new

call is taken before it is added to the incident log.

Key observation 5.8 : There is potential for Brigade Control personnel to experience secondary

trauma following a traumatic incident.

Theme 6 - Communications

Key observation 6.1 : The volume of radio traffic exceeded the capacity of both the BA and command

channels.

Key observation 6.2 : There is evidence of a lack of knowledge and understanding of the potential

tactics and associated equipment that may have mitigated radio communication issues.

Key observation 6.3: Senior officers were unable to book in attendance at the incident due to the

high volume of radio traffic on the Airwave main scheme radio.

Key observation 6.4 : There was a lack of information provided to Brigade Control on progress with

search and rescue operations.

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Key observation 6.5 : Dissemination of FSG information between the CU and the Bridgehead was

delivered via multiple channels as the volume and sources of information increased.

Key observation 6.6 : There was limited practical means to communicate with all residents in the

building to provide advice and / or support.

Key observation 6.7 : There was no declaration of a Firefighter Emergency to Brigade Control in

accordance with Policy Note 496.

Key observation 6.8 : From 0300hrs, FSG information was passed from Brigade Control to the

incident by a mobile to mobile communication link, resulting in a lack of evidence to support a post

incident review.

Theme 7 - Equipment

Key observation 7.1 : The Command Support System was unreliable during the incident.

Key observation 7.2 : There was no mobilising protocol for the Brigade’s limited Positive Pressure

Ventilation capability.

Key observation 7.3 : A number of BA sets were used more than once by different wearers and there

was no means to record the test or the subsequent wearer.

Key observation 7.4 : Time stamp on Thermal Image Cameras is not aligned to Greenwich Mean

Time.

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Chapter 5 – Summary of recommendations

Recommendation 1 - The Brigade should continue to work with all stakeholders to identify and

deliver improvements to the regulatory regime to prevent a re-occurrence of the Grenfell Tower fire

and increase the safety of the public and firefighters.

Recommendation 2 - The Brigade should continue to campaign vigorously for the provision of

sprinklers in residential high rise and other types of buildings in order to improve public safety.

Recommendation 3 – The Brigade should consider reviewing its policies and training packages

relevant to 7(2)d visits to ensure consistent guidance is provided to operational personnel.

Recommendation 4 – The Brigade should consider how to ensure information relating to identified

fire safety deficiencies in a premises is available to all operational crews.

Recommendation 5 - It is recommended that the Brigade determines whether to retain the DMM

or move to the DCP. It is acknowledged the Brigade needs to consider the challenges and benefits of

implementing such a wider ranging and fundamental change to its incident command framework, at a

time of significant organisational change and other improvement programmes.

Recommendation 6 - The Brigade should consider the extent to which human factors affecting

command and control are addressed in policy and training.

Recommendation 7 - The Brigade should consider how it can most effectively raise awareness of

and reinforce the requirements of PN 828 ‘Recording decision at incidents’.

Recommendation 8 – Whilst it is recognised that the volume of FSG calls experienced during the

Grenfell Tower fire and the information associated with those calls was unprecedented, it is

recommended the Brigade considers the issues carefully to ascertain if any measures can be

implemented to address this matter.

Recommendation 9 - The Brigade should consider to what extent recognition that a building is

behaving unpredictably in fire is addressed in policy and training.

Recommendation 10 - It is suggested the Brigade considers the extent to which policy, training and

human factors played a role in the control measure degradation identified.

Recommendation 11 - It is suggested the Brigade considers how shared situational awareness

within the Control room might be achieved in similar circumstances and whether a more

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sophisticated system than the whiteboards used on the 14th June should be developed and

implemented as an established Control protocol.

Recommendation 12 - The Brigade should consider whether any improvement measures are

necessary in relation to FFE policy and / or training.

Recommendation 13 - It is suggested that the Brigade considers whether it needs to make

operational staff more aware of the current available PPV capability and its uses.

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Chapter 6 - Appendices

Appendix A – Operational Response Report Volume One

Brigade reference: GTIRT19-00152

Inquiry reference: LFB 00032988

Appendix B – Actions by Brigade Control

Brigade reference: GTIRT18-03448

Inquiry reference: LFB 00004790

Appendix C – Organisational Overview

Brigade reference: GTIRT18-02288

Inquiry reference: LFB 00001905

Appendix D – Lakanal House Incident Assurance Review, August 2018

Brigade reference: GTIRT18_03758

Inquiry reference: Not applicable

Appendix E - National guidance and London Fire Brigade operational policy for fighting

fires in high rise buildings

Brigade reference: GTIRT19-00737

Inquiry reference: Not applicable

Appendix F – NFCC ‘Guidance to support a temporary change to a simultaneous

evacuation strategy in purpose-built block of flats’

Brigade reference: GTIRT18-02260

Inquiry reference: LFB 00024392 or HOM 00045969